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86-495
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4200/4300 - Liquid Waste/Water Well Permits
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86-495
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Last modified
9/7/2019 11:11:56 PM
Creation date
12/4/2017 10:21:16 PM
Metadata
Fields
Template:
EHD - Public
ProgramCode
4200/4300 - Liquid Waste/Water Well Permits
RECORD_ID
86-495
STREET_NUMBER
445
Direction
W
STREET_NAME
DOWNING
City
STOCKTON
SITE_LOCATION
445 W DOWNING
RECEIVED_DATE
05/19/1986
P_LOCATION
R L HUNGER
Supplemental fields
FilePath
\MIGRATIONS\D\DOWNING\445\86-495.PDF
QuestysFileName
86-495
QuestysRecordID
1716788
QuestysRecordType
12
Tags
EHD - Public
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APPLICATION FOR PERMIT <br /> ' 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 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. 1851 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. ,.. , <br /> Job Address �.�r moi/r -DO 4{2A) / 4) G City Lot size PM <br /> Owner's Name Address Phone /(� '] <br /> Contractor's Name i License No. Phone(;6W 1 <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION Z)PS 74-& <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL PLO. 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 ExcavationDia, of Well Casing <br /> L1 Domestic/Private ElGravel Pack ❑ Tracy Type of Casing s f Specifications <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by a' GI <br /> Repair Work Done ❑ Type of Pump 14.P. State Work Done <br /> r Well Destruction ❑ Well Diameter Sealing Material.{top 501 <br /> Depth Filler Material (Below 50')4. <br /> l <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is Q <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 <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 71 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." I I • r r*{ -0 ' 3 i <br /> The applicant must call f r all required inspections. Co plat drawing on reverse side. C� <br /> Signed &ZgkDate: <br /> FOR DEPARTMENT USE ONLY / <br /> Application Accepted by Date ( Area,_4 <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> ' Additional Comments: <br /> -❑-Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 8364M <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED CK RECEIVED By DATE PERMIT"N0. <br /> r + EH 1428(REV.101831 �. O J (p V\ - S/1 +{gk— -Li qS <br />
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