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87-3539
EnvironmentalHealth
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4200/4300 - Liquid Waste/Water Well Permits
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87-3539
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Last modified
11/17/2019 10:11:23 PM
Creation date
12/3/2017 5:27:03 AM
Metadata
Fields
Template:
EHD - Public
ProgramCode
4200/4300 - Liquid Waste/Water Well Permits
RECORD_ID
87-3539
STREET_NUMBER
555
STREET_NAME
N
STREET_TYPE
ST
SITE_LOCATION
555 N ST
RECEIVED_DATE
9/21/87
P_LOCATION
Y ZAVALA
Supplemental fields
FilePath
\MIGRATIONS\N\N\555\87-3539.PDF
QuestysFileName
87-3539
QuestysRecordID
1866475
QuestysRecordType
12
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EHD - Public
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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA NO�,3 <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1-YEAR 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 City A-klot Size PM <br /> Owner's Name �J Address Phone <br /> Contractor l _U�f lfJ �7� Address License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ 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 PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing (`N, <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> (`I Public ❑ 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 L3 Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material [top 50') <br /> Depth Filler Material IBelow 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION t 1 REPAIR/ADDITION i I DESTRUCTION 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 <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Notal length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS l I Depth Size Number <br /> SUMPS D Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS L7 <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 perVcher as to become subject to workman's compensation laws of California." Contractor's hiring or sub contracting signature <br /> certifies the fol wat in the performance of the work for which this permit is issued,1 shall employ persons subject to workman's compensa- <br /> tion laws of lifoThe applicanuired inspections. Complete drawing on reverse side. <br /> Signed X Title: �N./rL Date: Aw <br /> OR DEPARTMENT USE ONLY <br /> Application Accepted by ,Cit.� - R w..A � Date � Area <br /> Pit or Grout Inspection by // C� Date Final Inspection by Dat <br /> Additional Comments: /__ _9 <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 635-6385 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED CA H RECEIVED BY DATE PERMIT'NO. <br /> + EH13-24(REV. /n 51 3� 0 S _ <br /> £H 1a !,¢ I7 �sr1 <br /> J <br />
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