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87-2596
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4200/4300 - Liquid Waste/Water Well Permits
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87-2596
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Last modified
11/12/2019 10:09:32 PM
Creation date
12/2/2017 9:35:09 PM
Metadata
Fields
Template:
EHD - Public
ProgramCode
4200/4300 - Liquid Waste/Water Well Permits
RECORD_ID
85-2596
STREET_NUMBER
612
STREET_NAME
LILLIAN
STREET_TYPE
AVE
City
STOCKTON
SITE_LOCATION
612 LILLIAN AVE
RECEIVED_DATE
07/07/1987
P_LOCATION
KENNETH BRANT
Supplemental fields
FilePath
\MIGRATIONS\L\LILLIAN\612\87-2596.PDF
QuestysFileName
87-2596
QuestysRecordID
1821526
QuestysRecordType
12
Tags
EHD - Public
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F <br /> 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. <br /> Job Address t/ City k QC rh Lot Size Z4, C PM <br /> Owner's Name ����Ci r� �K177✓Address —L(/ � /� f7f Q Phone �J '2_ 43 <br /> Contractor_rS_,4-_e Address License No. Phone <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 Q Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> f'1 Public f 1 Other Cl 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 ❑ Type of Pump H.P, State Work Dane <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50') <br /> Depth Filler Material {Below 50'I <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAiR1ADDITION f I DESTRUCTION I No septic system permitted if public sewer is <br /> a ailable 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: Weil Foundation Property Line <br /> SEEPAGE PITS 1 I Depth Size _ Number <br /> SUMPS Ll Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> 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 mu It call for aIV1715uired inspections. CADirriplete drawing on reverse side. <br /> Signed X Title: Date: / <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date —7:_ Area <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> Additional Comments: <br /> ` osslbl <br /> ❑ Stk 466-6781 ❑ odi 36,9-3621 ❑ Manteca -7104 0 Tracy 835-6385 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 01 <br /> INFO FEE AMOUNT DUE AMOUNT REMITTED CK H RECEIVED BY DATE PERMIT NO. <br /> EH 13-24 r EH 14-28(REV.t H 51 ��� �} J ����� <br />
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