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88-613
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4200/4300 - Liquid Waste/Water Well Permits
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88-613
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Last modified
12/14/2019 10:11:17 PM
Creation date
12/3/2017 2:31:34 AM
Metadata
Fields
Template:
EHD - Public
ProgramCode
4200/4300 - Liquid Waste/Water Well Permits
RECORD_ID
88-613
STREET_NUMBER
3641
Direction
W
STREET_NAME
MICHIGAN
STREET_TYPE
AVE
City
STOCKTON
SITE_LOCATION
3641 W MICHIGAN AVE
RECEIVED_DATE
3/18/1988
P_LOCATION
THOMAS HUBBARD
Supplemental fields
FilePath
\MIGRATIONS\M\MICHIGAN\3641\88-613.PDF
QuestysFileName
88-613 (2)
QuestysRecordID
1851752
QuestysRecordType
12
Tags
EHD - Public
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LiY <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 TYEAR 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 37/* /�fjsL City -�r Lot Size (� PM <br /> Owner's Name �// /�/� AVI/Z AddresI fI t `""�" 7 Phone +w <br /> Contractor T 4)� Address License No. Phone_ <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTIO <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTH <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS r <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> J <br /> ❑ Industrial ❑ Open Bottom C1 Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> * Public M 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 ❑ Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Weil Diameter Sealing Material (top 501 � -., - _ <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION 1 I DESTRUCTION I ) INo septic system permitted if public sewer is <br /> available 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 f <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> a <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS I I Depth Size Number <br /> SUMPS L-1 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 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 I }orr wired 'ns ctigns. Co to drawing on reverse de.�/ -�'''�� <br /> Signed X Title: Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date Area <br /> Pit or Grout Inspection by ' Date Final Inspection byDate <br /> Additional Comments: d <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 El 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 <br /> CK 0 <br /> + � R`E/CE�IVED BY 3' DAnYTE� PERMIT-NO <br /> INFO CASHAMOUNT DUEMOUNT R </L.7 �-Z pbE14-241REV. 5) 3 �U <br /> ER 14-28 5 / 6Ly`J/ <br /> � ' <br />
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