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90-894
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4200/4300 - Liquid Waste/Water Well Permits
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90-894
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Last modified
3/9/2020 12:31:00 AM
Creation date
12/4/2017 11:37:37 PM
Metadata
Fields
Template:
EHD - Public
ProgramCode
4200/4300 - Liquid Waste/Water Well Permits
RECORD_ID
90-894
STREET_NUMBER
12810
Direction
N
STREET_NAME
EBERHARD
City
ACAMPO
SITE_LOCATION
12810 N EBERHARD
RECEIVED_DATE
4/16/1990
P_LOCATION
COXS
Supplemental fields
FilePath
\MIGRATIONS\E\EBERHARD\12810\90-894.PDF
QuestysFileName
90-894
QuestysRecordID
1722098
QuestysRecordType
12
Tags
EHD - Public
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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZETON AVE., STOCKTON, CA <br /> Telephone 12091 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. 1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District, Q� <br /> Job Address �(� be- 64,e� City Lot Size ��rf_ — PM <br /> r <br /> Owner's Name �� l Address Phone `� <br /> Contractor Address ? £ License No. h ne*'0'�r�� <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLA EMENT ❑ 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 /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> Ci Domestic/Private ❑ Gravel Pack l] Tracy Type of Casing Specifications <br /> * Public f) Other ❑ Delta Depth of Grout Seal`Type of Grout <br /> I I Irrigation --Approx. Depth I I Eastern Surface Seal installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50') <br /> Depth Filler Material (Below 50') I <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 1:1—REPAIR/ADDITION 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 <br /> 06 <br /> Character of soil to a depth of 3 feet: Water table depth J <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments G <br /> PKG, TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE No. & Length of lines !S r` _ Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation 14) Property Line <br /> SEEPAGE PITS yr Depth Size __ _ Numbe I <br /> SUMPS Cl Distance to nearest: Well ina Foundation Property Lin _ 1 <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."Contractors hiring or sub-contracting signature 0 <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 st It for I re Or d ins ctions. Complete drawing on reverse side. <br /> .1 r <br /> Signed X y Title: AI _.�_ Date: i <br /> . <br /> FOR DEPARTfiMENT'USE ONLY <br /> Application Accepted by [J Date11 r,-Z6 --qe <br /> O A eaa <br /> j <br /> }or Grout Inspection by Date r Final Inspection by Data (11211-111,Cf <br /> [Additional Comments: <br /> ❑ Stk. 466-6781 © Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant - Return all copies to: Environmental health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. <br /> + EH114-2&3-24/REV <br /> EH .sirrsl o.� o . JD '7 144-)6-110 190 <br />
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