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87-366
EnvironmentalHealth
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4200/4300 - Liquid Waste/Water Well Permits
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87-366
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Last modified
11/19/2019 10:07:00 PM
Creation date
12/1/2017 4:24:15 PM
Metadata
Fields
Template:
EHD - Public
ProgramCode
4200/4300 - Liquid Waste/Water Well Permits
RECORD_ID
87-366
STREET_NUMBER
541
Direction
N
STREET_NAME
ORO
STREET_TYPE
AVE
City
STOCKTON
SITE_LOCATION
541 N ORO AVE
RECEIVED_DATE
2/27/1987
P_LOCATION
RAY HICKEY
Supplemental fields
FilePath
\MIGRATIONS\O\ORO\541\87-366.PDF
QuestysFileName
87-366
QuestysRecordID
1886553
QuestysRecordType
12
Tags
EHD - Public
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f <br /> APPLICATION FOR PERMIT y <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL I 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. <br /> Job Address S ae JQ City Lot Size rr( l x IS PM <br /> 1 <br /> Owner's Name Address Phone <br /> Contractor Address License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑. WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ - <br /> DISTANCE TO NEAREST: SEPTIC TANK S ER LINES OSAL FLD. PROP. LINE <br /> FOUNDATION AGRI LTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CO�RUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca 'a. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy.,.- ' Typ of Casing Specifications <br /> ❑ Public ❑ Other ❑ Delta Depth Grout Seal Type of Grout <br /> ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Se nstalled by <br /> Repair Work Done ❑ Type of Pump,.- H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50') <br /> Depth Filler Material (Below 50'] It <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence_ Commercial_ Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. 0 Method of Disposal <br /> Distance to nearest: 11 Foun Property Line <br /> LEACHING LINE ❑ No. & Length of lines _ Total length/size r' <br /> FILTER BED ❑ Distance to nearest: ell Foundation Property Line <br /> SEEPAGE PITS ❑ Depth Size Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <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 parsons subject to workman's compensa- <br /> tion laws of California." <br /> a licant must a or all requirep�ections omplete drawing on reverse side. <br /> Signed Title: Date: Z` Z7—?Z <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date _1 Z� Area O <br /> Pit or Grout Inspection nb Date Final Inspection by Date <br /> Additional Comments. <br /> ❑ Stk 466-Ml ❑ Lodi 369-3621 ❑ teca 823-7104 ❑ Tracy 635-6385 <br /> Applicant-Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> INFO AMOUNT DUE AMOUNT REMITTED CIC RECEIVED BY FEEDATEEH 13-24 PERMIT'N0. <br /> + EH 14-281REV.F/851 ��• O7 <br />
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