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83-1146
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4200/4300 - Liquid Waste/Water Well Permits
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83-1146
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Last modified
8/2/2019 11:00:02 PM
Creation date
12/1/2017 12:29:17 PM
Metadata
Fields
Template:
EHD - Public
ProgramCode
4200/4300 - Liquid Waste/Water Well Permits
RECORD_ID
83-1146
STREET_NUMBER
10783
STREET_NAME
WAYNE
STREET_TYPE
CT
City
FRENCH CAMP
SITE_LOCATION
10783 WAYNE CT
RECEIVED_DATE
10/14/3
P_LOCATION
RANDY KROHN
Supplemental fields
FilePath
\MIGRATIONS\W\WAYNE\10783\83-1146.PDF
QuestysFileName
83-1146
QuestysRecordID
1980253
QuestysRecordType
12
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EHD - Public
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APPLICATION FOR PERMIT , t 3 �� I[� <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT 1 I1 ►,6 <br /> 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED DATE ISSUED 10-19+— <br /> (Complete <br /> 0-19+ -(Complete in Triplicate) F <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein <br /> described. This application is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump <br /> and the Rules and Regulations of the San Joaquin Local Health District. - U)GL&AM S. <br /> Job Address g Subdivision Name ' <br /> Owner's Name Address Phone47 JQx3" 7 T <br /> Contractor's Name License No. Phone <br /> I <br /> TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT DESTRUCTION ` <br /> PUMP INSTALLATION SYSTEM REPAIR OTHER <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE W k <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> 17 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation 4_7 t <br /> L�Iaomestic/Private <br /> 7 Grave] Pack F_�Tracy Dia, of Well Casing <br /> ❑ Public ❑Other Delta T <br /> Irrigation <br /> Type of Casing <br /> U 9 Approx. ❑ Eastern <br /> Depth Specifications <br /> Cathodic Protection p Depth of Grout Seal <br /> Geophysical <br /> Type of Grout <br /> Other <br /> Surface Seal Installed by <br /> Repair Work Done Type of Pumps u� H.P. i State Work Done <br /> Well Destruction Well Diameter Sealing Material (top 50') <br /> Depth Filler Material (Below 50') <br /> d <br /> TYPE OF SEPTIC WORK: NEke INSTALLATION ❑ REPAIR/ADDITION ❑ (No septic tank or seepage pit permitted if public sewer is <br /> available within ZOO feet.) oLl <br /> Installation will serve: Residence _ Commercial _ Other <br /> Number of living units: Number of bedrooms Lot size <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. Type/Mfg Capacity Method of Disposal , <br /> SEWAGE SYSTEM Distance to nearest: -Well Foundation Property Line <br /> DESTRUCTION ❑ 3}F ] <br /> f <br /> LEACHING LINE ❑ No. & Length of lines Total length/size + <br /> FILTER BED Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS Cj 'bepth Size _ Number i <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 <br /> ordinances, state laws, and 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 <br /> permit is issued, I shall not employ any person ,in such manner as to become subject to workman compensation laws of California." <br /> Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work for which <br /> this permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> The applicn ust ca 1 for al required inspections. Complete drawing on reverse side. <br /> i <br /> Signed X Title: Date: 3 <br /> FO DEP NT QE ONLx! <br /> Application Accepted by y�y�y.�rea Stk 466-6781 <br /> Additional Comments: [] Lodi 369-3621 <br /> Pit or Grout Inspection by Date Manteca 823-7104 <br /> Final Inspection by Date _ � 3 ❑ Tracy 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 BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO, <br /> INFO <br /> 45 <br /> EH 13-24 REV. 10/82 ��{ 2 7,0/ 590 <br /> 14-26 T �7 J <br />
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