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86-1273
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4200/4300 - Liquid Waste/Water Well Permits
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86-1273
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Last modified
9/1/2019 10:28:47 PM
Creation date
12/4/2017 5:29:50 PM
Metadata
Fields
Template:
EHD - Public
ProgramCode
4200/4300 - Liquid Waste/Water Well Permits
RECORD_ID
86-1273
STREET_NUMBER
25352
Direction
N
STREET_NAME
CHEROKEE
STREET_TYPE
RD
SITE_LOCATION
25352 N CHEROKEE RD
RECEIVED_DATE
09/29/1986
P_LOCATION
SKYLARK FARMS
Supplemental fields
FilePath
\MIGRATIONS\C\CHEROKEE\25352\86-1273.PDF
QuestysFileName
86-1273
QuestysRecordID
1687261
QuestysRecordType
12
Tags
EHD - Public
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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON 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. /� L <br /> Job Address t�5 3sa N. \ �'Gf . City Lot Size PM <br /> Owner's Name _ A 4 _ Address Z5 Q A), - � Phone <br /> Contrac Address1- 75, �C �L 7 License No.(32 Z(-Phone5 d <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 <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 QN <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done_ ul) <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 \J\ <br /> Depth ler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAI ADDITION DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Rest ence Commercial Other <br /> Number of living units: Number of rooms 3 <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 - t Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation f d ° Property Line 25' <br /> SEEPAGE PITS Depth Size Number CW �M <br /> SUMPS ❑ Distance to nearest: Well r Foundation Property Line j .__ <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:"1 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 ust call for all equir d inspections. Complete drawing an reverse de. <br /> Signed Title: V F Pi _ Date: q A=t4l-, eX94 <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Y, <br /> q Date Area <br /> Pit or Grout inspection by Date 9 Z2, IJA Final Inspection by Date <br /> Additional Comments: _ / <br /> ❑ Stk 466-6781 E3 Lodi 369-3621 ❑ Manteca 823-7104 LJ Tracy 8355-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE INFO AMOUNT DUE AMOUNT REMITTED CK CASH RECEIVED BY DATE PERMIT NO." <br /> + EH13-24 1REV.1J B 51 / ` <br /> EH 14-28 r C73 <br />
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