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86-701
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4200/4300 - Liquid Waste/Water Well Permits
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86-701
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Last modified
9/8/2019 10:15:47 PM
Creation date
12/1/2017 11:10:11 PM
Metadata
Fields
Template:
EHD - Public
ProgramCode
4200/4300 - Liquid Waste/Water Well Permits
RECORD_ID
86-701
STREET_NUMBER
4624
Direction
N
STREET_NAME
SUBURBAN
STREET_TYPE
RD
City
STOCKTON
SITE_LOCATION
4624 N SUBURBAN RD
RECEIVED_DATE
6/26/1986
P_LOCATION
JOANN SHEARER
Supplemental fields
FilePath
\MIGRATIONS\S\SUBURBAN\4624\86-701.PDF
QuestysFileName
86-701
QuestysRecordID
1938055
QuestysRecordType
12
Tags
EHD - Public
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APPLICATION FOFr 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. �y� <br /> Job Address �/� City_�//�Nr Loi Size Ply <br /> Owner's Name ddress Phone <br /> Azle" <br /> . ams. CJ <br /> Contractor�'lGy�r////s+ s �l Address License No. Phone! <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION X?Ai4l7GFnY. STEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINESt 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 /> ?Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal _ Type of Grout <br /> ❑ Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump _ H.P. State Work Done M !lam <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 Sti 1rr— /�37 ,! hG,�Jv <br /> Depth Filler Material (Below 501 <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 /> wuNumber of living units: Number of bedrooms <br /> t Character of soil to a depth of 3 feet: <br /> Water table depth <br /> SEPTIC TANK, ❑ Type/Mfg Capacity No. Compartments <br /> —'PKG. TREATMENT PLT. ❑ � Method of Disposal <br /> I Distance to nearest: Well Foundation Property Line <br /> r I <br /> ' LEACHING LINE// LI No. rAf No. & Lengtlines Total length/size <br /> :f FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS ❑ Depth Size _ Number <br /> Sl11UlP5, '7 r ❑ 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 persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant mus call for fl require s ctions. Gomplate drawing on reverses <br /> Signed X Title: s Date: Z <br /> FOR DEPARTMENT USE ONLY (^ n <br /> Application Accepted by Date �+/ 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 AMOUNT DUE AMOUNT REMITTED CASH CK 0 RECEIVED BY DATE PERMIT'NO. <br /> + EH 13,24(REV.Tins) <br /> EH 1426 ( •a.. r 1 !Q <br /> f <br />
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