My WebLink
|
Help
|
About
|
Sign Out
Home
Browse
Search
84-850
EnvironmentalHealth
>
EHD Program Facility Records by Street Name
>
W
>
WATERLOO
>
10200
>
4200/4300 - Liquid Waste/Water Well Permits
>
84-850
Metadata
Thumbnails
Annotations
Entry Properties
Last modified
8/18/2019 10:17:40 PM
Creation date
12/1/2017 12:00:09 PM
Metadata
Fields
Template:
EHD - Public
ProgramCode
4200/4300 - Liquid Waste/Water Well Permits
RECORD_ID
84-850
STREET_NUMBER
10200
Direction
E
STREET_NAME
WATERLOO
STREET_TYPE
RD
City
STOCKTON
SITE_LOCATION
10200 E WATERLOO RD
RECEIVED_DATE
07/10/1984
P_LOCATION
DONALD HICKS
Supplemental fields
FilePath
\MIGRATIONS\W\WATERLOO\10200\84-850.PDF
QuestysFileName
84-850
QuestysRecordID
1977237
QuestysRecordType
12
Tags
EHD - Public
There are no annotations on this page.
Document management portal powered by Laserfiche WebLink 9 © 1998-2015
Laserfiche.
All rights reserved.
/
2
PDF
Print
Pages to print
Enter page numbers and/or page ranges separated by commas. For example, 1,3,5-12.
After downloading, print the document using a PDF reader (e.g. Adobe Reader).
View images
View plain text
h <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL 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 /> ,, ., � <br /> Job Address 6,0 J'w T'F�.4e2j�2 AW City JLot Size PM <br /> Owner's Name De2A)It9/_Q /Y/Lf-_S Address 2426 kAZU e-0. IQD Phone <br /> Sys, / 4 <br /> Contractor's Name License No. Z -9Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION TEM 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 C1 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 /> -Repai"r-W6fDone--❑ "Typ®&-Pump ——H.P'_ State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50'1 <br /> Depth , Filler Material (Below WIN, <br /> -TYPE OF SEPTIC WORK: "NEW INSTALLATION'El' REPAIR/ADDITION ❑ DESTRUCTION ❑ Mo 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 <br /> j <br /> Distance to nearest: Well, Foundation I Property Line <br /> LEACHING LINE C] No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS ❑ Depth F Size Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> 1 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 /> I employ any person in such manner as to become subject to workman's compensation laws of California." Contractors 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 /> I The applicant m call for 11 requir d inspections. Complete drawing on reverse side. <br /> I 7 <br /> Signed X Title: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by .'�� . Date rea <br /> Pit or Grout Inspection by ~` Date "—� Final Inspection by e <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 36.9-3621 ❑ 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 85201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK# RECEIVED BY DATE PERMIT'NO. <br /> INFO CASH <br /> +EH 13-24(REV.10183) <br /> EH 16-26 <br />
The URL can be used to link to this page
Your browser does not support the video tag.