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89-1039
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4200/4300 - Liquid Waste/Water Well Permits
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89-1039
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Last modified
12/18/2019 10:08:12 PM
Creation date
12/2/2017 9:19:32 PM
Metadata
Fields
Template:
EHD - Public
ProgramCode
4200/4300 - Liquid Waste/Water Well Permits
RECORD_ID
89-1039
STREET_NUMBER
0
STREET_NAME
LIBERTY
STREET_TYPE
RD
RECEIVED_DATE
4/28/1989
P_LOCATION
CAMANCHE CONSTRUCTION
Supplemental fields
FilePath
\MIGRATIONS\L\LIBERTY\0\89-1039.PDF
QuestysFileName
89-1039
QuestysRecordID
1820331
QuestysRecordType
12
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EHD - Public
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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 r/� ✓'�, r_���� <br /> Job Address'y M ( G `--G 15City Lot Size Q CtVZd, PM <br /> W Y'i' <br /> r 3�Owner's Nam Address + Phone <br /> Contract r Address,&A" _Ie L___l�e'License N flu' Phon <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ 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 C1 Tracy Type of Casing Specifications <br /> i'i Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation _Approx. Depth I I Eastern Surface Seal Installed by : <br /> Repair Work Done U Type of Pump H.P, State Work Done_ <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> Depth Filler Material (Below 5011, <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 1 1 R;'i'AIR/ADDITION I I DESTRUCTION l I INo septic system permitted if public sewer is <br /> available within 200 feet./ <br /> Installation will serve: Residence X Commercial— Other <br /> Number of living units: __/_ Number of droo s' C <br /> Character of sail to a depth of 3 feet: Water table depth <br /> SEPTIC TANK Type/Mfg e� Capacity—/20-0 No. Compartments <br /> r <br /> PKG. TREATMENT PL ❑ / of Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE No. & Length of lines 720 - Total length/size <br /> Of <br /> FILTER BED ❑ Distance to nearest: Well Foundation- �In , Property Line %_:5: -_- <br /> SEEPAGE PITS Depth Size Number <br /> SUMPS ❑ 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 Di3trict. <br /> Home owner or licensed agent's signature certifies the following: "I certify that in fhe 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 /> f <br /> The applicant call forq ed inspections. Complete drawing on faverse d <br /> Signed X Title: , Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted b <br /> PP P Y Date Area <br /> Pit or Grout Inspection by D t+ rnal Inspection by -fe.64of <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 95201FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. <br /> + EH 1324 IREV.iiH51 <br /> EH 14-26 U� <br /> ro <br />
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