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90-1055
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4200/4300 - Liquid Waste/Water Well Permits
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90-1055
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Last modified
1/19/2020 12:14:51 AM
Creation date
12/1/2017 9:12:43 PM
Metadata
Fields
Template:
EHD - Public
ProgramCode
4200/4300 - Liquid Waste/Water Well Permits
RECORD_ID
90-1055
STREET_NUMBER
5540
Direction
E
STREET_NAME
SHIPPEE
STREET_TYPE
LN
City
STOCKTON
SITE_LOCATION
5540 E SHIPPEE LN
RECEIVED_DATE
5/4/1990
P_LOCATION
RAND SPRAGGINS
Supplemental fields
FilePath
\MIGRATIONS\S\SHIPPEE\5540\90-1055.PDF
QuestysFileName
90-1055
QuestysRecordID
1923729
QuestysRecordType
12
Tags
EHD - Public
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4 APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE 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. � �/�T� <br /> Job Address Cityc `�`�'�" Lot Size PM <br /> Owner's Name � �,9 Address r _-_ Phone t�4 <br /> on dresdw-/-*(,ense No. Phone�� <br /> TYPE OF WELL/PUMP: NEW WELL © WELL REPLACEM NT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK f \ SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> 17 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> F1 Public ❑,Other Cl Delta Depth of Grout Seal Type of Grout _ <br /> I I Irrigation Approx. D th "IEgp��� Surface Seal installed byRepair Work pone ❑ Type of Pu State Work Done <br /> __. <br /> Well Destruction ❑ Well D' imeter i Sealing Material (top 50') <br /> Dept Filler Material (Below 60') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 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 ' VA <br /> Number of living units:," -_Nu ber.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 <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of linesTotal length/size ' <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS I I Depth Size Number <br /> SUMPS E 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, 1 shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applica us calf or a uired spections. Complete dra ' g on�Side.orTitle. Date: <br /> FO EPARTMENT USE ONLY <br /> 1 <br /> Application Accepted by r Date �1 Area v <br /> Pit or Grout Inspection by Date Final Inspection by �` Date <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 AMOt�UNT DUE AMOUNT REMITTED CASH RECEIVED BY PATE PERMIT NO. <br /> ♦ EH13-28 <br /> 24Iq EV.5iN51 <br /> EH 14- <br />
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