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93-0189
EnvironmentalHealth
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EIGHT MILE
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4200/4300 - Liquid Waste/Water Well Permits
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93-0189
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Last modified
5/3/2020 10:37:36 PM
Creation date
12/5/2017 12:06:21 AM
Metadata
Fields
Template:
EHD - Public
ProgramCode
4200/4300 - Liquid Waste/Water Well Permits
RECORD_ID
93-0189
STREET_NUMBER
4520
Direction
W
STREET_NAME
EIGHT MILE
STREET_TYPE
RD
City
STOCKTON
SITE_LOCATION
4520 W EIGHT MILE RD
RECEIVED_DATE
02/03/1993
P_LOCATION
COUNTY OF SAN JOAQUIN
Supplemental fields
FilePath
\MIGRATIONS\E\EIGHT MILE\4520\93-0189.PDF
QuestysFileName
93-0189
QuestysRecordID
1724307
QuestysRecordType
12
Tags
EHD - Public
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APPLICATON FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> i 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. 1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. 0 & r 2? . <br /> Job Address City Stc&xot Size PM <br /> Owner's Name f• Address Phone <br /> Contractor Address • &OaC.Aq icense Nol 10 Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR k OTHER Eli DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OT6 ER 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 /> — _E]--Oomestic/-Private...._ i❑ Gravel.Pack-_L]Tracy..._._._,..,,,....,.,Type of Casing r I Specifications <br /> �Q Public ❑ Other Cl Delta Depth of Grout Sea! I Type of Grout <br /> I I Irrigation 4 --Approx. Depth l I Eastern., R Surface Seal installed byAce X—m-M <br /> 1 <br /> Repair Work Done 0 Type of Pump H.P.'-• State Work Done <br /> Well Destruction ❑ Well 1A) Sea i(ng Material (top 50') ""' A I <br /> i Depth * Filler Material )Below 501 s : j <br /> TYPE OF SEPTIC WORK: NE INS ALLATION I'] REPAIR/ADDITION l I DESTRUCTION i IP(No septic system permit d if public sewer is <br /> .� ' p available within 200 feet.)1. <br /> Installation will serve: Residence— 'Commercial —Other— --4 � <br /> Number of living units:L—/ Number of bedrooms <br /> Character of soil to a fiepthlof 3 feet: Uzi ~` 1/Vater EIRMAn <br /> r SEPTIC TANK t (-]I Type/Mfg + '` 'f '� Capacity ! `t- r5o. CrED <br /> `1 <br /> PKG. TREATMENT PLT. ❑; ( 3 Meth �l ol` <br /> ."Distance newest: Well —.Foundation Property Lin <br /> "�..✓" 'l SANJOAOUINCOIINTY <br /> LEACHING LINE Cf"wato. & Lendilh of fines Toial len LIC HEALTH SERVICES <br /> tr f P HEALTH DIVISION <br /> FILTER BED.;;. .. ;, _© -Dijtance. to nearest: WO rr Foundation } Property Lme <br /> SEEPAGE PITS I 1 Depth Size _ Number I <br /> SUMPS LiZDistance to nearest: Well _ Foundation Property Line <br /> DISPOSAL-PQNQS._---❑ <br /> I. a I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin counfy ordinances, state laws;-and <br /> ' rules and,regulations of the San Joaquin Local Health Diltrict. <br /> „Homeowner 4 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.tfoting: <br /> uch manner as to become subject to workman's compensation laws of CAlifornia." Contractor's hiring or sub-contracting signature <br /> certifiesI 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 law " <br /> The appfo a re fired ins ns. Complete drawing o e r e side. <br /> r " <br /> Signed Title: Date: <br /> _ 1 i <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date�G� 4 Area V)N' <br /> �J <br /> Pit or Grout Inspection by Date Fina{ inspection by Date <br /> Additional Comments: F (� <br /> 1 ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> a Applicant - Return all copies to. Environmental Health Permit/Services 1601 E. Hazelton Ave., .0. Box 2009, Stk., CA 95201 r�{� <br /> PEE AMOUNT DUE AMOUNT REMITTEDC SH RECEIVED BY DA7E PERMIT'NO. <br /> c <br /> +�EH 13- <br /> IN <br /> IREV.w/H 5] <br /> EH 14-26 <br />
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