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87-1130
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4200/4300 - Liquid Waste/Water Well Permits
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87-1130
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Last modified
9/10/2019 10:23:02 PM
Creation date
12/4/2017 4:49:08 PM
Metadata
Fields
Template:
EHD - Public
ProgramCode
4200/4300 - Liquid Waste/Water Well Permits
RECORD_ID
87-1130
STREET_NUMBER
248
Direction
S
STREET_NAME
CARROLL
STREET_TYPE
AVE
City
STOCKTON
SITE_LOCATION
248 S CARROLL AVE
RECEIVED_DATE
4/3/1987
P_LOCATION
PETE ETCHEVERRY
Supplemental fields
FilePath
\MIGRATIONS\C\CARROLL\248\87-1130.PDF
QuestysFileName
87-1130
QuestysRecordID
1681196
QuestysRecordType
12
Tags
EHD - Public
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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 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 /> N � ... •. - i n . is <br /> Job Address �T`d .S Ci4.@,GULL Y City �J" LotSizePM <br /> .5 . . <br /> Owner's Name Address Phone <br /> Contractor Address License No. - Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ,I <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑-t. <br /> DISTANCE TO NEAREST"SEPTIC-TANK" "^ ^'--SEWER-LINES---------- --'--DISPOSAL FLb.� 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 _ d <br /> ❑ Domestic/Private ❑ Gravel Pack ' ❑ Tracy Type of Casing Specifications <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal - ' Type of Grout <br /> ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by } <br /> Repair Work Done ❑ Type of Pump H.P. State Work II <br /> Well Destruction ❑ Well Diameter Sealing Material {top 501 _ + <br /> Depth Filler Material (Below 501 p <br /> T PE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is' - <br /> available within 200 feet.) <br /> Installation wr Residence— Commercial_ Other <br /> Number of living units: ber of bedrooms_ r <br /> Character of soil to a depth of 3 feet: € -- ""`�.r <br /> Water table depth <br /> SEPTIC TANK ❑ Type/Mfg t F Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ f Method of Disposal C - <br /> Distance to nearest: Well Foun n Property Line <br /> LEACHING LINE ❑ No. & Length of lines - - Total Wsize <br /> s <br /> FILTER BED I] Distance:to nearest: Well Foundation Propert e <br /> SEEPAGE PITS ❑ Depth Size -t Number <br /> SUMPS ❑ Distance to nearest: Well r 4 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 mus II SII requir J' spe s. Complete drawing on rev rse side. y <br /> rl <br /> Signed Title: -� - - bate: N —o <br /> FOR DEPARTMENT USE ONLY <br /> Application Acc ted by Date O Area <br /> Pit or Grout Inspection by Date Final Inspection by Date � - <br /> Additional Comments: I <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O.:Box 2009, StII CA 93201 <br /> FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT N0. <br /> _ f ; <br />
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