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87-1386
EnvironmentalHealth
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4200/4300 - Liquid Waste/Water Well Permits
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87-1386
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Entry Properties
Last modified
9/13/2019 9:07:36 AM
Creation date
12/1/2017 4:04:43 PM
Metadata
Fields
Template:
EHD - Public
ProgramCode
4200/4300 - Liquid Waste/Water Well Permits
RECORD_ID
87-1386
STREET_NUMBER
411
Direction
S
STREET_NAME
OLIVE
STREET_TYPE
AVE
City
STOCKTON
SITE_LOCATION
411 S OLIVE AVE
RECEIVED_DATE
04/15/1987
P_LOCATION
HAROLD H HIROSE
Supplemental fields
FilePath
\MIGRATIONS\O\OLIVE\411\87-1386.PDF
QuestysFileName
87-1386
QuestysRecordID
1883848
QuestysRecordType
12
Tags
EHD - Public
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APPLICATION.FOR PERMIT <br /> Cy <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601'E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described.This application is <br /> 'made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. /tr- <br /> Job Address ` ��4 0 ] t+ <br /> City Lot Size 1 J`~d PM <br /> u n <br /> �r Owner's Name '�` �� / /C ►�S� Address Phone`� 1 <br /> Contractor Address <br /> License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ \' <br /> } PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEA E TIC TANK - SEWER LINES DISPOSAL FLD. LINE <br /> FOUNDA AGRICULTURE WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM A CTION SPECIFICATIONS <br /> 171 Industrial ❑ Open Bottom ❑ Ma Dia. of vation Dia. of Well Casing 1 <br /> f ❑ Domestic/Private ❑ Gravel Pack Tracy Type of Casing Specifications <br /> ❑ Public ❑ Othe Cl Delta Depth of Grout Seal �Type Grout <br /> ❑ Irrigation _Approx. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Q ❑ Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material {top 50'1 , <br /> Depth Filler Material (Below 50')' <br /> TYPE OF SEPTIC WORK:, ANEW INSTALLATION ❑ REPAIR/ADDITION-0DESTRUCTION (No septic system permitted if public sewer is <br /> vailable within 200 feet.l <br /> Installation will serve: Residence_ Commercial , 066--' <br /> Number of living units: '� `r Number of bedrooms cc t <br /> .,-r. <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg 1 Capaci <br /> ry No. Compartments <br /> PKG. TREATMENT PLT. ❑ t <br /> Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> i <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ExDistto nearest: Well Foundation Property Line <br /> SEEPAGE PITS ❑l✓Depth Size Number <br /> SUMPS ❑ Distance tonearest: ` Well Foundation Property Line <br /> DISPOSAL PONDS .❑ f <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin Local Health District. <br /> Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not <br /> employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature <br /> certifies the following:"I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant rf ust call for all required in ctions. Complete drawing on reverse side. <br /> Signed Title: Date: <br /> _12 ' <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by 7 D 3 k <br /> Date �� Area <br /> Pit or Grout Inspection by -7 Date Final Inspection by Date <br /> Additional Comments: .0 o� .SS <br /> ❑ Stk 466-6781 ❑ Lodi" 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant- Return all copies to; Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED K RECEIVED BY DATE PERMIT NO. <br /> INFO pp CASH } <br /> + EH 13-26-REV. /as) (5 � �r—GG{7 <br /> EH 1426 [��.. <br />
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