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4200/4300 - Liquid Waste/Water Well Permits
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86-1260
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Last modified
9/1/2019 10:27:46 PM
Creation date
12/2/2017 1:20:24 PM
Metadata
Fields
Template:
EHD - Public
ProgramCode
4200/4300 - Liquid Waste/Water Well Permits
RECORD_ID
86-1260
STREET_NUMBER
19544
Direction
W
STREET_NAME
GRANT LINE
STREET_TYPE
RD
City
TRACY
SITE_LOCATION
19544 W GRANT LINE RD
RECEIVED_DATE
9/30/1986
P_LOCATION
BETTY ENGLISH
Supplemental fields
FilePath
\MIGRATIONS\G\GRANT LINE\19544\86-1260.PDF
QuestysFileName
86-1260
QuestysRecordID
1790411
QuestysRecordType
12
Tags
EHD - Public
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APPLICATION FOR PERMIT Q�C/ <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. , <br /> Job Address bi&,,4Z�d- ity Lot Size PM <br /> Owner's Name 0 Address A) Phon .- <br /> Contractor's Name License No._ 4 . 2 Phone o� � <br /> TYPE OF WELL/PUMP: NE_ ELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION Pl-_'00 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 Al <br /> ❑ In trial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> C�lDomestic/Private ❑ Gravel Pack C�?racy Type of Casing Specifications <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation --Approx. b ❑ Eastern S c eal Installed by <br /> Repair Work Done ❑ Type of Pum pGH.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material Itop 501 <br /> Depth Filler Material {Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ Mo septic system permitted if public sewer is <br /> available within 200 feet.), G <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 /> r <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS ❑ Depth Size Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS Cl <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 must call for all required inspections. Complete drawing on reverse side. $ <br /> 40�Signed Title � Date: <br /> `�C FOR DEPARTMENT USE ONLY ,,{� <br /> Application Accepted by - 1 CJ1 Cf, Date '4� Area Q / <br /> Pit or Grout Inspection by Date Final Inspection by yz�lkk h, DateR`wj�ja <br /> Additional Comments: <br /> 4 Stk 466-6761 ❑ Lodi 369-3621 ❑ Manteca 823-7104 KTracy 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 AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT"NO. <br /> INFO C <br /> +EH EH 13-281REV.16183! 3-5 �� <br /> , O 7 <br /> f <br />
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