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89-1839
EnvironmentalHealth
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4200/4300 - Liquid Waste/Water Well Permits
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89-1839
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Last modified
11/19/2024 10:18:58 AM
Creation date
12/5/2017 12:44:15 AM
Metadata
Fields
Template:
EHD - Public
ProgramCode
4200/4300 - Liquid Waste/Water Well Permits
RECORD_ID
89-1839
STREET_NUMBER
4835
Direction
W
STREET_NAME
ELEVENTH
STREET_TYPE
ST
City
TRACY
SITE_LOCATION
4835 W ELEVENTH ST
RECEIVED_DATE
8/1/1989
P_LOCATION
TOM BERTRAM / LONDONER APT
Supplemental fields
FilePath
\MIGRATIONS\E\ELEVENTH\4835\89-1839.PDF
QuestysFileName
89-1839
QuestysRecordID
1728350
QuestysRecordType
12
Tags
EHD - Public
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F APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 JUL 3 T 1 $g <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED E'IV1P0'N <br /> N4FNTAL HFA <br /> (Complete in Triplicate) PE!?mvr/gEOC:fUJ <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 welllpump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> Job Address ` City Lot Size PM <br /> Owner's Name �� � %� Address ����--per Phone <br /> I/ r <br /> Contractor <br /> �� ddress �� �lv; +� License No. � Phontf —` <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES} DISPOSAL FLO. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial 17 Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> f'�'Ipublic Cl Other ❑ Delta Depth of Grout Seal Type of Grout <br /> II I Irrigation —.Approx. Depth I 1 Eastern Surface Seal installed by <br /> Repair Work Done Type of Pumper H.P. State Work Done lint' <br /> Weil Destruction ❑ Well Diameter Sealing Material {top 501 pC1 <br /> Depth Filler Material (Below 50'1 — � 1 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 HEPAIRIADDITION l I DESTRUCTION i I (No septic system permitted if public sewer is <br /> available within 200 fest.) <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 _n <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ %� Method of Disposal <br /> Distance to nearest: Well Foundation _ Property Line <br /> h, 1 <br /> LEACHING LINE ❑` No. & Length of lines Total length/size <br /> FILTER BED d Distance to nearest: Well Foundation - Property Line 1 <br /> SEEPAGE PITS I I Depth Size Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line _ 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 of 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 must call,f9T a14 requireinspections. Complete drawing onverse side. �7 <br /> Signed X y Title: 9--�— Date: 7-2-1 <br /> —2 <br /> R DEPA TMENT USE ONLY <br /> Application Accepted by Date Areas <br /> Pit or Grout Inspection by Date Final Inspection by to <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 623-7104 ❑ Tracy 835-6385 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2008, Stk., CA 95201 <br /> FEE I <br /> INFO AMO+U/�NT DUE AMOUNT REMITTED CK 4 CASH RECEIVED BY DATE PERMIT-NO. <br /> +.EH13-241REV.i/H51 -s . Cl rr4 fit- f�39 <br /> EH 14-16 ✓✓✓ <br /> �i <br />
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