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85-1173
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4200/4300 - Liquid Waste/Water Well Permits
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85-1173
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Entry Properties
Last modified
8/20/2019 10:19:00 PM
Creation date
12/4/2017 6:51:10 PM
Metadata
Fields
Template:
EHD - Public
ProgramCode
4200/4300 - Liquid Waste/Water Well Permits
RECORD_ID
85-1173
STREET_NUMBER
11337
Direction
W
STREET_NAME
CLOVER
STREET_TYPE
RD
City
TRACY
SITE_LOCATION
11337 W CLOVER RD
RECEIVED_DATE
09/26/1985
P_LOCATION
JOSE FARIA
Supplemental fields
FilePath
\MIGRATIONS\C\CLOVER\11337\85-1173.PDF
QuestysFileName
85-1173
QuestysRecordID
1694132
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) t <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. TMs application is J <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 /> Job Address " �Y w �al/-Q�- • �- City Lot Size PM <br /> `� CX tT ! hone / G6 <br /> Owner's Name�/0$'-e F r'I Ci Address - <br /> I <br /> e <br /> 7� <br /> Contractor's Name License No. L(Ndi <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT DESTRUCTION ❑ I <br /> PUMP INSTALLATION Q' SYSTEM REP IR 13cOTTHH�R ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES I�I DISPOSAL FLD.] 2_L PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ r <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIO S <br /> L1Industrial C1Open Bottom ❑ Manteca Dia. of Well Excav ti of Well Casing (a`� t <br /> Aomestic/Private Gravel Pack racy Type of Casing Specifications <br /> F-1Public E] Other ❑ Delta Depth of Grout Sea Type of Grouts <br /> ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by CL(14#-- I ( � <br /> Repair Work Done ❑ Type of Pump W.P. State Work Done <br /> Well <br /> estruction 171 Well Diameter _ Sealing Material (top 501CACI f -�J <br /> Depth Filler Material (Below 501 <br /> TYPE(OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitteii if public,sewer is 'A <br /> available within 200 feet.) ! <br /> 1 1 ! <br /> Installation will serve: Residence_ Commercial_ Other t l <br /> Number of living units: Number of bedrooms <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 Total length/size 1 l <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line I <br /> �4 <br /> SEEPAGE PITS ❑ Depth Size Number , <br /> SUMPS ❑ Distance to-nearest: Well• Foundation 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 i <br /> rules and regulations of the San Joaquin Local Health District. I - r <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 s 11 for II requird i spections. Complete drawing on r rse si _ <br /> Signed Title: Date: <br /> FOR D�RTT USE ONLYApplication Accepted by jjr Da <br /> Pit or Grout Inspection by Date1� Final f sp on by Date <br /> Additional Comments: I <br /> ❑ Stk 466-6781 ❑ Lodi 309-3621 ❑ Manteca 823-7104 Tracy 636 <br /> Applicant- Return ail copies to: Environmental Health Permit/Services 1601 E. Hlihelton Ave., P.O. o <br /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIV`NO. <br /> INFO CASH <br /> + EH13-24(REV.10183) <br /> EH 14-28 <br />
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