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89-430
EnvironmentalHealth
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COOLIDGE
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4200/4300 - Liquid Waste/Water Well Permits
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89-430
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Last modified
1/8/2020 10:13:23 PM
Creation date
12/4/2017 7:42:56 PM
Metadata
Fields
Template:
EHD - Public
ProgramCode
4200/4300 - Liquid Waste/Water Well Permits
RECORD_ID
89-430
STREET_NUMBER
1031
Direction
S
STREET_NAME
COOLIDGE
City
STOCKTON
SITE_LOCATION
1031 S COOLIDGE
RECEIVED_DATE
03/03/1989
P_LOCATION
MARLEY COOLING TWR
Supplemental fields
FilePath
\MIGRATIONS\C\COOLIDGE\1031\89-430.PDF
QuestysFileName
89-430
QuestysRecordID
1700071
QuestysRecordType
12
Tags
EHD - Public
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w A APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE 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 thr q`bl' cribed. This application is <br /> made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump anfi �s� egulations of the San Joaquin <br /> Local Health District. <br /> 03 �. Gd0 C-1V0� Cit Jf�G�a /�/ Lat Size PM <br /> Job Address Y <br /> Owner's Name 6Ot^- � _ Address �` �'GCfI-!/� Phone 6cr <br /> r,,/ J,�f <br /> Contractor�ly� WWX,?W// Address �¢*sFr o License No. " '"(337 Phone3 ,??—QQzT <br /> TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION Fr' SYSTEM REPAIR © OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK Z SEWER LINES 2-47~ DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICAT ONS <br /> ,Klndustrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private J�rGr` aavvel_P_ack Cl Tracy Type of Casing ^� �' Specifications <br /> FI Public 0therrW00V/ 1l Delta Depth of Grout Seal /J Z- Type of Grout. <br /> I i Irrigation —.-Approx. Depth I I Eastern , Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump f UBS H.P. �Z _ State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 Q <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIRlADDITION I.I DESTRUCTION I I (No septic system permitted it 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 /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments M <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 /> 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 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, Ihal,e�ryRlpy.�ye{ 1� e� tgsrt owmGT <br /> tion laws of California." AENVIROINMENTAL HEALTH DIVISION <br /> The applicant m t call for re u' d inspections. Complete drawing on <br /> reverse side. <br /> SPECIAL � <br /> Signed X Title: �DT Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date -' <br /> Pit or Grout Inspection by Data Final <br /> lljIInspection b Data `� <br /> Additional Comments: _!1/_LG �l� l��,1d,Rf <br /> ❑ Stk 466-6781 . ❑ Lodi 369-3621 ❑ Manteca 82J-7104 ❑ Tracy 835-6365 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> CK i <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED GASH RECEIVED BY DATE PERMITNO. F <br /> VCS x. f^U � A <br /> +.EH 13-24(r1EY.i i N s) 35' .7 00 Fit l S 3 —3 <br /> -�EH 14-2a - <br />
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