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87-2825
EnvironmentalHealth
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4200/4300 - Liquid Waste/Water Well Permits
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87-2825
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Entry Properties
Last modified
11/14/2019 10:07:30 PM
Creation date
12/2/2017 9:50:15 PM
Metadata
Fields
Template:
EHD - Public
ProgramCode
4200/4300 - Liquid Waste/Water Well Permits
RECORD_ID
87-2825
STREET_NUMBER
7681
Direction
W
STREET_NAME
LINNE
STREET_TYPE
RD
City
TRACY
SITE_LOCATION
7681 W LINNE RD
RECEIVED_DATE
07/27/1987
P_LOCATION
FORNASERO
Supplemental fields
FilePath
\MIGRATIONS\L\LINNE\7681\87-2825.PDF
QuestysFileName
87-2825
QuestysRecordID
1822807
QuestysRecordType
12
Tags
EHD - Public
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i <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601, E. HAZELTON AVE., STOCKTON, CA <br /> Telephone 12091_466-6781 <br /> y <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> r. (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 : G <br /> City TLot Size PM <br /> „ry ' <br /> Owner's Name � � � Address � P f' -?,9�7 <br /> Phone <br /> Contractor + Address_� ��� rPf �`� 3'��_lcense nZE �3y Phone �76i6 <br /> TYPE OF WELL/PUMP: NEW WELL CJ WELL REPLACEMENT ❑ DESTRUC_TION ❑ <br /> .PUMP INSTALLATION E3 SYSTEM REPAIR ❑ O`fHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK ,'SEWER LINES DISPOSAL FLD.- PROP. LINE,- <br /> LL �� <br /> FO AGRICULTURE WEOTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBL CONSTRUCTIONSPECIFICATIONS <br /> ❑ Industrial ❑ Open.Bottom. ❑ Manteca Dia. o xcavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy ,Type of Casing,i "L Specifications <br /> ❑ Public Ll Other ❑ Delta f Depth.of Grout Seal Type of Grout yx <br /> ❑ Irrigation �pprox.;Depth Eastern _ Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump ter-- H.P. ' State Work Done X / <br /> Well Destruction ❑ Well Diameter "' Sealing Material {top-50')•. <br /> _r= rf <br /> Depth, Filler Material {Below 50'1 <br /> TYPE OF SEPTIC WORK: NEIN INSTALLATION ❑p REPAIR/ADDITIONI.DESTRUCTION ❑ (No septic system permitted if,public sewer is— <br /> available within 200 feet.) <br /> Installation will serve: Residence_ Commercial— Other t "1 - E <br /> ! <br /> Number of living units:' Number of b1 edrooms <br /> Character of soil to.a depth of 3 feet:. °--- -- - - ater table depth <br /> SEPTIC TANK ❑ Type/Mfg r Capacity No. Compartments <br /> 1. PKG. TREATMENT PLT. ED ! ! Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> L I <br /> LEACHING LINE ' No & Length of lines }i /�T _ Total length/size �� ��`• l <br /> FILTER'BED ❑ Distance to nearest: Well Foundation Property Line /r <br /> SEEPAGE PITS i 1] Depth Size Number <br /> SUMPS ❑ Distance,to nearest: Well Foundation___-� Property Line <br /> DISPOSAL PONDS. ❑ 1 I' <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 ma er as to become subject to workma4l, compensation laws of California."Contracto�s'hiring or subcontracting signature <br /> certifies the following:"I c hat 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 c f uired ' clip mplete drawing on reverse side. <br /> F <br /> f <br /> " Signed Title: _ Date: 7 Z <br /> FOR DEPARTMENT USE ONLY �} <br /> Applicaiion"Accepte&by mm 1 "T Date "' Area <br /> 2f <br /> Pit or Grout Inspection by � Date Final Inspection by Date <br /> C' <br /> ditional Comments: <br /> iWtk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy•"835 386,1 <br /> Applicant- Return all copies for Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95101 <br /> FEE INFO AMOUNT DUE- AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. -.. <br /> EH 1428 <br /> + EH 13.24(REV.1/s 51 O <br /> - - ... .. .-. <br />
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