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87-822
EnvironmentalHealth
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4200/4300 - Liquid Waste/Water Well Permits
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87-822
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Last modified
11/26/2019 10:12:31 PM
Creation date
12/4/2017 4:10:35 PM
Metadata
Fields
Template:
EHD - Public
ProgramCode
4200/4300 - Liquid Waste/Water Well Permits
RECORD_ID
87-822
PE
4366
STREET_NUMBER
16601
Direction
S
STREET_NAME
CAMPBELL
STREET_TYPE
RD
City
ESCALON
SITE_LOCATION
16601 S CAMPBELL RD
RECEIVED_DATE
03/17/1987
P_LOCATION
ROBERT SURRELL
Supplemental fields
FilePath
\MIGRATIONS\C\CAMPBELL\16601\87-822.PDF
QuestysFileName
87-822
QuestysRecordID
1677189
QuestysRecordType
12
Tags
EHD - Public
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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <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 / / r.� A City 1e ot'Size —Z PM <br /> Owner's Name U � Address �L/r�U L �.� �� Phone <br /> i <br /> Contractor ' Address,2-352-S l cense No._9WA_&3L Phone 6 <br /> TYPE OF WELL/PUMP: V NEW WELL. WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK PWX �-e SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL- PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS �� Q <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation n Dia. of Well Casing <br /> XDomestic/Private Gravel Pack ❑ Tracy Type of Casing /�, Specifications <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal �fl Type of Gro <br /> ❑ Irrigation --Approx. Depth ❑ Eastern 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 501 <br /> i <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> t 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 <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS ❑ 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 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 Califo nia." <br /> The applic t m t call for all require spections. 96mplete drawing on re se side. <br /> Signed Title: Date: <br /> FOR PARTNEENDT USE ONLY <br /> Application Accepted by Date Area <br /> '7 f <br /> Pit or Grout Inspection by rrff Date ��- Final lnspe on by r Date <br /> Additional Comments: � iJt �ct/t • Cot I <br /> ❑ Stk 466-6781 ❑ Lodi 369 ❑ Manteca 823-7104 ❑ Tracy 635-6385 r t1 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA'95201FEE <br /> v ' <br /> INFO AMOUNT DUE AMOUNT REMITTED CK RECEIVED <br /> BY DAT�iEf �( PERMIT'NO. Z <br /> + EH13-24 1REV.1/85) y /� �—I � cru l�Dq� /\N <br /> EH 14-28 <br />
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