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89-1343
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4200/4300 - Liquid Waste/Water Well Permits
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89-1343
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Last modified
12/22/2019 10:06:53 PM
Creation date
12/4/2017 5:22:53 PM
Metadata
Fields
Template:
EHD - Public
ProgramCode
4200/4300 - Liquid Waste/Water Well Permits
RECORD_ID
89-1343
STREET_NUMBER
1820
Direction
S
STREET_NAME
CHEROKEE
City
LODI
SITE_LOCATION
1820 S CHEROKEE
RECEIVED_DATE
06/12/1989
P_LOCATION
MANUEL
Supplemental fields
FilePath
\MIGRATIONS\C\CHEROKEE\1820\89-1343.PDF
QuestysFileName
89-1343
QuestysRecordID
1686280
QuestysRecordType
12
Tags
EHD - Public
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�Y APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZETON AVE., STOCKTON, CA <br /> Telephone (209) 46";181 — L\1¢ <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 /> ty.7�i <br /> 461 1.11 <br /> k' Job Address f3oct/ �'r��c` _ City Lot Size PM <br /> Owner's Name Address r Phone f <br /> Contractor <br /> Address c—� License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ .WELL REPLACEMENT ❑ DESTRUCTION 2 <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> ,l 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 /> F ❑ Industrial ❑ Open Bottom ❑ Manteca Dia- of Well Excavation Dia. of Well Casing, <br /> ❑ Domestic/Private ❑-Gravel Pack ❑ Tracy Type of Casing Specifications <br /> f'1 Public ❑ Other. ❑ Delta Depth of Grout Seal Type of Grout <br /> E•l Irrigation Approx. Depth i I Eastern _F° '"Surlace Seal Installed by - <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction 'Well Diameter Sealing Material (top 501 % 441C_4/Q <br /> ` Depth Filler Material (Below 501 _4-~^-4f <br /> i TYPE OF SEPTIC WORK: NEW INSTALLATION l 1 REPAIR/ADDITION l 1 DESTRUCTION. IIlld 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 /> t SEPTIC TANK ❑ Type/Mfg Capacity' No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> ti <br /> Distance to nearest: Well Foundation Property Line <br /> r , <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> l FILTER BED ❑ Distance to nearest: %Well Foundation Property Line <br /> F SEEPAGE PITS I 1 Depth Size Number <br /> 1 SUMPS ❑ Distance to nearest: Well 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 Di'ltrict. -' <br /> t 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 a requirSo insUpetions. Complete drawing on reverse side. f' <br /> Title: _ ���/ Date: <br /> 42 <br /> Signed X <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by I - 00,w Date Area <br /> I Pit or Grout Inspection by Date Final Inspection by Date <br /> r Additional Comments: <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, Stk., CA 95201 _ <br /> FEEAMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. <br /> INFO <br /> +.EH 13-24{BEY'.r i n 51 %Z:7 7 <br /> EH 14-26 <br />
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