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89-695
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4200/4300 - Liquid Waste/Water Well Permits
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89-695
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Last modified
1/9/2020 10:07:19 PM
Creation date
12/1/2017 1:38:03 PM
Metadata
Fields
Template:
EHD - Public
ProgramCode
4200/4300 - Liquid Waste/Water Well Permits
RECORD_ID
89-695
STREET_NUMBER
3631
Direction
N
STREET_NAME
WILMARTH
STREET_TYPE
RD
SITE_LOCATION
3631 N WILMARTH RD
RECEIVED_DATE
4/4/89
P_LOCATION
YOUNG
Supplemental fields
FilePath
\MIGRATIONS\W\WILMARTH\3631\89-695.PDF
QuestysFileName
89-695
QuestysRecordID
1987603
QuestysRecordType
12
Tags
EHD - Public
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P.' <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZETON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> 4 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED f <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. 1 <br /> Job Address City Lot Size PM <br /> Owner's Name <br /> Address <br /> �J �-"���J ZPhone <br /> i <br /> Contractor <br /> Address License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT IDDESTRUCTION ❑ <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 �r <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> Fl Public ❑ Other C] Delta Depth of Grout Seal Type of Grout,_. -_. <br /> I I Irrigation --Approx. Depth +1 I Eastern Surface Seal Installed by - <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done w <br /> Well Destruction ❑ Well Diameter Sealing Material Itop 501 <br /> Depth Filler Material (Below 50 -- <br /> TYPE OF SEPTIC WORK; NEW INSTALLATION 1.1 REPAIRlADOITION I I DESTRUCTION I (No septic system permitted if public sewer is <br /> vailable within 200 feet.i- <br /> Installation will serve: Residence— Commercial— Other <br /> Number of living units: Number of bedrooms <br /> l <br /> Character of soil to a depth of 3 feet: Water table-depth f <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 <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS I I Depth Size Number <br /> i SUMPS Ll 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 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: "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 Califgr�a ll" <br /> a <br /> The applicant trust all refit re pections. Complete drawing on reverse side. <br /> tl �j Signed X Title: Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date~ Area q <br /> Pit or Grout Inspection by G� Data Final Inspection by Date <br /> Q/ <br /> I 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 /> FEE AMOUNT DUE AMOUNT REMITTED CK 4 SH HECE ED BY DATE PERMIT N . <br /> i INFO <br /> +.EH 13.24(REV.1/H 5) S2&z <br /> -(p <br /> EH 14-28 <br />
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