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90-2705
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4200/4300 - Liquid Waste/Water Well Permits
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90-2705
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Last modified
2/27/2020 10:14:40 PM
Creation date
12/4/2017 5:10:10 PM
Metadata
Fields
Template:
EHD - Public
ProgramCode
4200/4300 - Liquid Waste/Water Well Permits
RECORD_ID
90-2705
STREET_NUMBER
3040
STREET_NAME
CENTER
STREET_TYPE
ST
City
ACAMPO
SITE_LOCATION
3040 ACAMPO ST
RECEIVED_DATE
10/09/1990
P_LOCATION
JERRY GRELLE
Supplemental fields
FilePath
\MIGRATIONS\C\CENTER\3040\90-2705.PDF
QuestysFileName
90-2705
QuestysRecordID
1683654
QuestysRecordType
12
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EHD - Public
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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> (209) 468-3447 <br /> PERMIT EXPIRES 1 EAR rROM DATE ISSUED <br /> ;I I Y <br /> (Complete in Triplicate) <br /> V <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work herein described. This <br /> application is made in c64liance With San Joaquin County Ordinance.No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public <br /> Health Services. <br /> Job Address Y S <br /> .�O d �' �T Cit AA PB Lot Size/Acreage <br /> ,I <br /> Ownor'o Name :T�E2�y1 i2�E-A�4 -- Address c e6 1W -61',y 421,-- !_4_ Al Phone <br /> it <br /> Contractor_JE44 +�D GrJc fa Address 7 AD�� License No, �7 S"y7t Phone '=3 <br /> TYPE OF WELL/PUMP: �� NEW WEL C1WELL REPLACEMA <br /> T 0 DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION SYSTE R ❑ OTHER ❑ Monitoring Well C] <br /> r DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> k FOUNDATION GRICULTLIWELL OTHER WELL PITS/SUMPS .� <br /> .F <br /> INTENDED USE TYPE OF WELL PROBLE R CONSTRUCTION SPECIFICATIONS <br /> 17.1 Industrial ❑,Open Bottom ❑ Mantec Dia. of Well Excavation Dia. of Well Casing <br /> U Domestic/Private .O Gravel Pack ❑ Tie Type of Casing Specifications <br /> i <br /> M Public 171 Other © Oita �Su <br /> of Grout Seal Type of Grout <br /> CI Ifrigaiion ��.Approx, Depth Eastern e Seal Installed by <br /> Repair Work Done ❑ Type of Pump H:P: State Work Done <br /> Well Destruction O Weil Diameter ' Sealing Material i Depth <br /> pep1h Filler >!tateriiiil"i-Depth" '" T"" "" <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION D REPAIR IADDITIONDESTRUCTION CI (No septic system permitted if public sewer is <br /> J1 available within 200 feet.) <br /> Installation will server Residence_t""'Comrnercial_ Other <br /> Number of living units: Number of bedrooms ..J= !" <br /> Character of soil to a depth of 3 feet: .4_d6Q V 0 Z_ 4 Water table depth <br /> SEPTIC TANK f ❑ Type/Mfg —__ '(1 S r-i A1- --" - Capacity 'No. Compartments <br /> PKG. TREATMENT PLT. 0 A k , Method of Disposal <br /> .Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE J No. & Length of lines J Total length/Size ` ^L <br /> «i <br /> FILTER BED Cl Distance to nearest: Well A_ Foundation Property Line ` <br /> �f <br /> SEEPAGE PITS I,1/ DepthS� Sire 's Number <br /> SUMPS Lt Distance to nearest: Well ^ Foundation Property Line -� <br /> DISPOSAL PONDS El 'IM. <br /> I hereby certify that I have prt3pared 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 Sen Joaquin County <br /> Home owner or licensed agenCPs signature certifies the following; "I certify that in the pertormance 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&Il'�rsquired inspectio s, Complete drawing on reverse_side......, - r <br /> Signed X. Title: Date: <br /> 0 >rPARTMENT USE ONLY G L1CC <br /> ��ticc ti � "�l� Area Y� <br /> A scion Accepted by � t�,,,a_. � --_` Data <br /> Pito rout Inspection by�1�1( '�T > -,Date ���� _Final.lnapection.b �'�'` ;,.,__ Data <br /> dditlonal Comments: I� _ <br /> Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> 1[ ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> 4 445 N SAN JOAQUIN, P O BOX 2009, STOCKTON. CA (x5201 <br /> INFOFEE AMOUINT DUE AMOUNT nEM3TTED CASH RECEIVED BY DATE PERMIT'NO. <br /> %F1. EH 13-24 IREV.It"51 .II qo- a2 <br /> EH .4.26 ``� f J r !� �-g <br /> 5 II „ <br />
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