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87-4345
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4200/4300 - Liquid Waste/Water Well Permits
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87-4345
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Last modified
11/24/2019 10:08:07 PM
Creation date
12/2/2017 12:39:23 PM
Metadata
Fields
Template:
EHD - Public
ProgramCode
4200/4300 - Liquid Waste/Water Well Permits
RECORD_ID
87-4345
STREET_NUMBER
339
Direction
S
STREET_NAME
GERTRUDE
City
STOCKTON
SITE_LOCATION
339 S GERTRUDE
RECEIVED_DATE
12/22/1987
P_LOCATION
EVELYN BUSBY
Supplemental fields
FilePath
\MIGRATIONS\G\GERTRUDE\339\87-4345.PDF
QuestysFileName
87-4345
QuestysRecordID
1785143
QuestysRecordType
12
Tags
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 TYEAR 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. b��>fQ U�� ✓/� City�r/��% Lot Size PM <br /> Owner's NamePhone <br /> Address <br /> Contractor — C Address License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL. ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION 0 SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK 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 /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> F1 Public F Other ❑ Delta _Depth of Grout Seal Type of Grout _ <br /> I I Irrigation —Approx. Depth I I Eastern Surface Seal Installed by t _ <br /> Repair Work Done ❑ Type of Pump H.P. State Work Dane_ <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION i 1 REPAIR/ADDITION I I DESTRUCTIQ (No septic system permitted it public sewer is <br /> variable 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 <br /> Distance to nearest: Well Foundation Property Line <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 0 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 call for all required inspections Complete drawing on reverse side. <br /> Signed X Title: i _ Date: 1.2—.1 <br /> FOR DEPARTMENT USE ONLY <br /> (r� i <br /> Application Accepted by _A( �,ADate 1 —�� '� '-T Area <br /> p y .L�."-�. Date <br /> Pit or Grout Inspection by - Date Final Inspection b 2� F <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 RECEIVED BY DATE PERMIT_NO. <br /> + EH13-24(REV.1 i H 55 '2 �, <br /> EH 14-2e C/ <br />
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