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87-3160
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4200/4300 - Liquid Waste/Water Well Permits
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87-3160
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Last modified
11/15/2019 10:07:14 PM
Creation date
12/3/2017 2:45:19 AM
Metadata
Fields
Template:
EHD - Public
ProgramCode
4200/4300 - Liquid Waste/Water Well Permits
RECORD_ID
87-3160
STREET_NUMBER
5275
Direction
E
STREET_NAME
MILLER
City
STOCKTON
SITE_LOCATION
5275 E MILLER
RECEIVED_DATE
8/21/1987
P_LOCATION
TRACEY TRAMMELL
Supplemental fields
FilePath
\MIGRATIONS\M\MILLER\5275\87-3160.PDF
QuestysFileName
87-3160
QuestysRecordID
1853360
QuestysRecordType
12
Tags
EHD - Public
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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON 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 welUpump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> L <br /> {ddress �l City Lot Size PM <br /> r's Name Address Phone <br /> actor Address ��3 WLLicense No. Phone � r <br /> TYPE OF WELL/PUMP:(,,.,' NEW WELL ❑ WELL REPLACEMENT L] DESTRUCTION ❑ <br /> PUMP INSTALLATION Q 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 PR LEM AR CONST CTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ anteca DI Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy pe o sin <br /> g Specifications <br /> f'] Public F Other Cl Delta Depth of Grou at Type of Grout <br /> 1 1 Irrigation �_Approx. Depth I ] star Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H,P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> Depth Filler Material (Below 50') l <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIR/ADDITION I I DESTRUCTION X(No septic system permitted if public sewer is 1 <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 <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size (1Q. <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS l I Depth Size Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> 1 hereby certify that I have prepared this application and that the work will he 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 must call for all <br /> required inspections. Complete drawing on reverse side. J, <br /> .,1 Signed — r i� �..- Title: Date: <br /> FOR DEPARTMENT USE ONLY r <br /> Application Accepted by Date FC) <br /> Ole, Area <br /> Pit or Grout Inspection by p �to Final Inspection by Date <br /> r <br /> Additional Comments: L <br /> El 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-&385 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E, Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE INFO AMOUNT DUE AMOUNT REMITTED AS RECEIVED BY DATE PERMIT'NO. <br /> a EH 13-24 IREV. <br /> EH 14-26 pil! <br />
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