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86-1298
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4200/4300 - Liquid Waste/Water Well Permits
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86-1298
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Last modified
9/1/2019 10:31:14 PM
Creation date
12/4/2017 6:31:59 PM
Metadata
Fields
Template:
EHD - Public
ProgramCode
4200/4300 - Liquid Waste/Water Well Permits
RECORD_ID
86-1298
STREET_NUMBER
194
Direction
W
STREET_NAME
CLAYTON
City
STOCKTON
SITE_LOCATION
194 W CLAYTON
RECEIVED_DATE
10/09/1986
P_LOCATION
LEE HENRY
Supplemental fields
FilePath
\MIGRATIONS\C\CLAYTON\194\86-1298.PDF
QuestysFileName
86-1298
QuestysRecordID
1691941
QuestysRecordType
12
Tags
EHD - Public
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A <br /> 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 Regulation of the San Joaquin f <br /> Local Health District. <br /> r Job Address Ci A) I- - <br /> City <br /> Lot Size ! P144 <br /> Owner's Name _ w Address Phone N' <br /> SA )+ _L <br /> Contractor L 7hLAddress 1 js T& l lit <br /> License Na. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR 11 OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLb. PROP. LINED <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS < l <br /> IJ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation � I� <br /> Dia. of Well Casing 3 <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specificationsp. <br /> { ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Groutls <br /> ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by <br /> C Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> I Well Destruction ❑ Well Diameter Sealing Material Itop 501) !� N <br /> Depth Filler Material (Below 501 I� <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION (No septic system permitted if public sewer is C'• <br /> y available within 200 feet.) <br /> k Installation will serve: Residence— Commercial_ Other <br />[f Number of living units: Number of bedrooms f j <br /> Character of soil to a depth of 3 feet: 1 <br /> Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ t <br /> ' 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 j <br /> f SEEPAGE PITS ❑ Depth _ Size Number IM <br /> SUMPS ❑ Distance to nearest: Well Foundationi <br /> Property Line <br /> DISPOSAL PONDS ❑ <br /> 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 permitpis 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' <br /> p n is issued,I shall employ persons subject to workman's compensa- <br /> tion laws of California." � pe�sa <br /> 14 The appli ant t call for all required inspections. Complete drawing on reverse side. I <br /> t I ��Signed Title: i Date: <br /> FOR EPARTMENT USE ONLY { <br /> Application Acceptedby Date ^–� <br /> Area <br /> �J <br /> Pit or Grout Inspection b <br /> pe Y Date Final Inspection by — 'i <br /> Additional Comments: t l 4 7�, <br /> ❑ Stk 466-6781 ❑ Lodi 369-362 ❑ Manteca =4104 <br /> Ll Tracy 8354M <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 i <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED 8Y DATcE� / PERMIT NO. <br /> + EH14-2BEH 13-24 C�IREV.tiie51 3SOF I q�Q 10— I�W f11ll�I 111 <br /> _ i <br />
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