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87-1241
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4200/4300 - Liquid Waste/Water Well Permits
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87-1241
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Entry Properties
Last modified
9/11/2019 10:12:53 PM
Creation date
12/4/2017 9:36:10 PM
Metadata
Fields
Template:
EHD - Public
ProgramCode
4200/4300 - Liquid Waste/Water Well Permits
RECORD_ID
87-1241
STREET_NUMBER
118
Direction
S
STREET_NAME
DAWES
STREET_TYPE
AVE
City
STOCKTON
SITE_LOCATION
118 S DAWES AVE
RECEIVED_DATE
04/08/1987
P_LOCATION
JUANE GALLARDO
Supplemental fields
FilePath
\MIGRATIONS\D\DAWES\118\87-1241.PDF
QuestysFileName
87-1241
QuestysRecordID
1712039
QuestysRecordType
12
Tags
EHD - Public
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APPLICATION FOR PERMIT A <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL—i ON AVE., STOCKTON, CA <br /> Telephone (200) 466-6781 <br /> s <br /> PERMIT EXPIRES i YEAR FROM DATE ISSUED <br /> ( IComplete 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 f <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 J 1�.�'~i I r !�(�fK� Q <br /> City Lot Size PM J <br /> Owner's Name Address /a 0� �� ry L` Phone "Y6 7--303 IS <br /> Contractor Address License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> .,PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ 1 OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK,-' SEINER LINES '` """ � "R DISPOSAL FLD, PROP. LINE <br /> 1 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 <br /> ❑ Domestic/Private ❑ Gravel Packs ❑ Tracy Type of Casing i Specifications <br /> ❑ Public ❑ Other ` k ❑ Delta Depth of Grout Sea! Type of Grout <br /> ❑ Irrigation '---Approx. Depth . ❑ Eastern Surface Seal Installed by. I <br /> Repair Work Done ❑ Type of Pump H.P. - State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> Depth Filler Material (Below 501 ; <br /> TYPE OF SEPTIC WORK: a NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION (No septic system permitted if public sewer is <br /> F Sivailable within 200 feet.) <br /> Installation will serve: Residence 'Commercial_ Other <br /> Number of living units: Numberl of bedrooms <br /> Character of soil to a depth of 3 feet: ' Water table depth + <br /> SEPTIC TANK -10 Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. O 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 /> 'r , <br /> SEEPAGE PITS ❑ 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,I shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant ust call for all required inspections. Complete'drawing on reverse side. <br /> Signed Title: Date:��G i <br /> e FOji DEPARTMENT USE ONLY <br /> Application Accepted by c Date C Area <br /> Pit or Grout Inspection by ' " 'Date T' Final Inspection by Dat <br /> ` <br /> Additional Comments: 7 '✓ f ti0 d Q,re d <br /> ❑ Stk 466-6781 ❑ Lodi 369- ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E:Hazekon Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED CK# RECEIVED BY DATE PERMITNO. <br /> + 3-24 IREV.f/a51 <br /> EH 142 <br /> OJi t , <br />
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