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91-0766
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4200/4300 - Liquid Waste/Water Well Permits
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91-0766
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Last modified
3/12/2020 11:01:35 AM
Creation date
12/3/2017 1:32:50 AM
Metadata
Fields
Template:
EHD - Public
ProgramCode
4200/4300 - Liquid Waste/Water Well Permits
RECORD_ID
91-0766
STREET_NUMBER
5759
STREET_NAME
MARSH
STREET_TYPE
ST
City
STOCKTON
SITE_LOCATION
5759 MARSH ST
RECEIVED_DATE
04/10/1991
P_LOCATION
LARRY W GIFFORD
Supplemental fields
FilePath
\MIGRATIONS\M\MARSH\5759\91-0766.PDF
QuestysFileName
91-0766
QuestysRecordID
1846338
QuestysRecordType
12
Tags
EHD - Public
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APPL I CATI ON FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES NV W5Vtg-� . <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 1601 E. HAZELTON AVE. , PHONE (209)468--3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> MIRES 1 YEAR FROM D TE ED <br /> (Complete in Triplicate) <br /> Application is hereby made.to San Joaquin County for a permit to construct and/or install the Work herein described. This <br /> application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> 5 7 9 116 � ✓/ _ City a f\fb`r Lot Size/Acreage I <br /> Job Address _l <br /> Owner's Name , ^ -) ' ' `4%]/� ` <br /> �!{ OI(l' Address ^ �S Phone <br /> ' <br /> Contractor Address License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION Ll Out of Service Well ❑ <br /> PUMP INSTALLATION O <br /> SYSTEM REPAIR ❑ OTHER 'Monitoring Well L7 <br /> DISTANCE TO NEAREST: Sf PTIC TANK SEWER LINES DISPOSAL F PROP. LINE <br /> FOUND AGRICULTURE WELL WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM ARE S ION SPECIFICATIONS <br /> C1 Industrial © Open Bottom ❑ Manteca is. of cavation Dia. of Well Casing <br /> 4DomesticlPrivate. ❑ Gravel Pack Ci T Type of Casing Specifications <br /> F1 Public Cl Other n Delta Depth of Grout Seal Type of Grout <br /> i I Irrigation fox. Depth I I Eastern Surface Seat installed by <br /> Repair Work Done 0 Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material & Depth <br /> Depth Filler Material:& Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 1 1 REPAIR/ADDITION I i DESTRUCTION I®(No septic system permitted if public sewer is <br /> available within 200 feet) <br /> Installation will serve: Residence Z Commercial_,..^ Other <br /> Number of living units: _L_ Number of bedrooms .21 <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 D No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS I I Depth Size ___ Number <br /> SUMPS CI 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 taws, and <br /> rules and regulations of the San Joaquin County v+ <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 woikrnan'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 must call for all squired in ctions. Complete drawing on reverse side. <br /> Signed t Title: 0`'y tvG k ___ .- - Date: 4 :Y-62-7 11 <br /> 1 <br /> FO DEPARTMENT USE ONLY <br /> Application Accepted by Date d Area ri1 <br /> Pit or Grout Inspection by Date Final Inspection by 2 '� Date <br /> Additional Comments: <br /> r <br /> Applicant - Return all copies to: San Joaquin County Public Health <br /> Services, Environmental Health Permit/Services <br /> i, 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED SASH RECEIVED BY DATE PERMIT NO. <br /> INFO � �" ( � � <br /> . EH 13-24(REV.r/95)50 <br /> - D`"' �`--S�`� <br /> EH 14-25 1 <br /> 4 - <br />
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