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90-3168
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4200/4300 - Liquid Waste/Water Well Permits
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90-3168
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Last modified
3/2/2020 2:28:41 AM
Creation date
12/1/2017 7:58:00 PM
Metadata
Fields
Template:
EHD - Public
ProgramCode
4200/4300 - Liquid Waste/Water Well Permits
RECORD_ID
90-3168
STREET_NAME
SANTA FE
STREET_TYPE
RD
City
ESCALON
SITE_LOCATION
SANTA FE AND RIVER RD
RECEIVED_DATE
12/06/1990
Supplemental fields
FilePath
\MIGRATIONS\S\SANTA FE\0\90-3168.PDF
QuestysFileName
90-3168
QuestysRecordID
1915328
QuestysRecordType
12
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EHD - Public
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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON 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 549 for-sea or No. 1862 for well/pump and the Rules a Regulations of the San Joaquin <br /> Local Health Distric u r r <br /> Job Address 5 �+-� Q cd O`cu�S �"�'Q City f b�"I� Lot Size PM <br /> v"r"'• t <br /> Owner's N e Address Phone <br /> - <br /> Contractor ��ey`�� �intf�llG� Address �ter 'n��`r" �� LicenseNo.T�+�t Phones 's <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION t <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR 71 OTHER L� �d;J �4rl ,5 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE J U. <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS rys- <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing / 5pecifications VP—�@h�y aw <br /> M Public Cl Other F Delta Depth of Grout Seal tl� l Type of Groutqe—,,evl!) r <br /> i I Irrigation _Approx. Depth I i Eastern Surface Seal Installed by <-)% � <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material Itop 50') <br /> Depth Filler Material (.Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR/ADDITION I I DESTRUCTION I 1 INo 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. ❑ Method of Disposal t t <br /> Distance to nearest: Well Foundation Property Line { <br /> I� I <br /> I <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS I I Depth Size _ Number <br /> SUMPS L] Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> hereby certify that I have prepared this application and that the work will he done in accordance with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin Local Health Di$trict. <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 uWfll uired inspections. Complete drawing on reverse side. <br /> Signed X Title: �� �� ` I L Date: <br /> I <br /> f. R DEPARTMENT USE ONLY <br /> Application Accepted by Data r Area <br /> Pit or Grout Inspection by Date Final Inspection by Date% <br /> I <br /> Additional Comments: <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 <br /> INFO AMOUNTDUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIYNO, <br /> ♦.EH13-24/REV.t i n 51 �—?b ' <br /> 4-26 <br /> EH 1 (V , <br />
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