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4200/4300 - Liquid Waste/Water Well Permits
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89-640
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Last modified
1/9/2020 10:06:24 PM
Creation date
12/4/2017 7:54:04 PM
Metadata
Fields
Template:
EHD - Public
ProgramCode
4200/4300 - Liquid Waste/Water Well Permits
RECORD_ID
89-640
STREET_NUMBER
11674
STREET_NAME
COPPEROPOLIS
STREET_TYPE
RD
City
STOCKTON
SITE_LOCATION
11674 COPPEROPOLIS RD
RECEIVED_DATE
03/31/1989
P_LOCATION
TOM MOOR
Supplemental fields
FilePath
\MIGRATIONS\C\COPPEROPOLIS\11674\89-640.PDF
QuestysFileName
89-640
QuestysRecordID
1701739
QuestysRecordType
12
Tags
EHD - Public
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i APPLICATION FOR PERMIT <br /> 1 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 he+eby 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. <br /> o- <br /> Job Address City Lot Size PM <br /> Owner's Name Address k� Phone <br /> Contractor4zresS License No./ Phone a-- �7 <br /> TYPE OF WELL/ UMP: I 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 /> l; <br /> ❑ Industrial ❑ Open Bottom O Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gfavel Pack ❑ Tracy Type of Casing Specifications <br /> FI Public D Other n Delta" Depth of Grout Seal Type of Grout <br /> p I I Irrigation �..Approx. Depth ,I I Eastern. _ Surface Seal Installed by _ <br /> f[ Repair Work Done U Type`of Pump H.P. State Work Done _ <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50') <br /> Depth Filler Material (Below 1 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION E DESTRUCTION l I (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence Commercial_ Other <br /> Number of living units: �� Number of bedrooms �r <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. ❑ i. Method of Disposal <br /> Distance to nearest: - Well Foundation Property Line <br /> LEACHING`LINE Cl No. &.Length of lines Total length/size <br /> FILTER BED ..❑ Distance to nearest: Well Foundation Property Line <br /> EPAGE PIT 11 Depth Siza Nufnber ! r- <br /> -SUMPS ❑ Distance to nearest: Well]�20I Foundation�� Property Line f to `� Q <br /> DISPOSAL PONDS 0 7 <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. 'D <br /> Home owner or licensed agent's signature certifies the following; 1 certify that in the performance of the work for which this permit is issued, I shall not C! <br /> I 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." L7 <br /> The applicant mu It c I f required ins ti s. Compl 0 wing on reverse side. _ <br /> Signed X Date: may- <br /> * FOR DEPARTMENT USE ONLY <br /> Application Accepted by 6i . Date [ Area �C�1 <br /> i Pit or Grout Inspection by Date 3_`��_�? Final Inspection by Date 7 �3 f <br /> Additional Comments: 2-C t� W L Zis GA Lo A.ir <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 5! a <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.Q. Box 2009, Stk., CA 95201 fav G1c3 w Lv <br /> P---fie <br /> IF <br /> O AMOUNT DUE AMOUNT REMITTED CK It CASH ' RECEIVED BY DATE PERMIT-NO. <br /> p <br /> f' <br /> EH 14-Z6 <br /> ♦ EH13-24IREV.tiAt) <br /> '^ 7 <br />
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