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4200/4300 - Liquid Waste/Water Well Permits
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83-1261
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Last modified
8/3/2019 10:49:34 PM
Creation date
12/4/2017 8:36:19 PM
Metadata
Fields
Template:
EHD - Public
ProgramCode
4200/4300 - Liquid Waste/Water Well Permits
RECORD_ID
83-1261
STREET_NUMBER
16110
STREET_NAME
COTTAGE
City
MANTECA
SITE_LOCATION
16110 COTTAGE
RECEIVED_DATE
11/09/1983
P_LOCATION
LEROY PRATER
Supplemental fields
FilePath
\MIGRATIONS\C\COTTAGE\16110\83-1261.PDF
QuestysFileName
83-1261
QuestysRecordID
1704918
QuestysRecordType
12
Tags
EHD - Public
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APPLICATION FOR PERMIT <br /> 5AN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1501' E. HAZELTON AVE., STOCKTON, CA PERMIT NO,� <br /> Telephone (209) 466-6781 <br /> DATE ISSUED <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby made to the San:Joaquin LocaI Health District for a permit to construct and/or install the work herein W <br /> described. This application is made in compliance with San Joaquin .County Ordinance No. 549 for sewage or No. 1862 for well/pump <br /> and the Rules and Regulations of the San Joaquin Local Health District. <br /> � <br /> Job Address (`! dolstid i <br /> Owner's Name Address Phone Q� <br /> Contractor's Name License No. 6 Phone 9 r � <br /> TYPE OF WELL/PUMP WORK: 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 /> 6 . <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Industrial U Open Bottom ❑ Manteca Dia. of Well Excavation C} <br /> Domestic/Private ❑Gravel Pack ❑ Tracy Dia, of Well Casing <br /> ❑ Public ❑ Other ❑ Delta Type of Casing <br /> Irrigation Approx. ❑ Eastern i <br /> Cathodic Protection <br /> Depth Specifications <br /> Depth of Grout Seal q <br /> ❑Geophysical Type of Grout pC <br /> ❑Other Surface Seal Ins ailed by j <br /> Repair Work Done ❑ Type of Pump IAL L11- h.P. I State Work Don ii <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50')` . ._ <br /> i <br /> Depth Filler Material (Below 501) <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ,❑ REPAIR/ADDITION ❑ (No septic tank or seepage pit permitted if public sewer is I' <br /> s` available within 200 feet.) <br /> Installation will serve: Residence Commercial _ Other <br /> Number of living units: Number of bedrooms Lot size <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. ❑ Type/Mfg Capacity Method of Disposal <br /> SEWAGE SYSTEM Distance to nearest: Well Foundation Property Line <br /> DESTRUCTION <br /> LEACHING LINE ❑ No, & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS ❑ Depth Size Number <br /> SUMPS ❑ Distance to nearest: ,Well Foundation Property Line <br /> DISPOSAL PONDS ❑I "' - <br /> i <br /> 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county <br /> ordinances, state laws, and 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 ' <br /> permit is issued, I shall not employ any person in such manner as to become subject to workman compensation laws of California." <br /> Contractor's hiring or sub-contracting'signature certifies the following: "I certify that in the performance of the work for which <br /> this permit is issued, 1 shall employ persons subject to workman's compensation laws of California." <br /> The applicant ust cali-4pIr all required inspections. Complete dr 'ng on reverse side. (} <br /> Signed x QQ 6_,.. Title: �.-� Date: <br /> FO RTMENT USE ONLY <br /> Application Accepted by Area' ____ ❑. Stk 466-5781 <br /> Additional Comments: ❑ Lodi 369-3621 <br /> i <br /> Pit or Grout Inspection by Date �j K Manteca 823-7104 <br /> Final Inspection by Date /L Tracy 835-6385 <br /> Applicant - Return all copies t% Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE BASE AMOUNT DUE .1: AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. <br /> INFO , <br /> EH 13-24 REV. 10/82 �' 10/82 500 <br /> 14-26 � <br />
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