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87-2625
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ELLIOTT
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4200/4300 - Liquid Waste/Water Well Permits
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87-2625
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Last modified
11/13/2019 10:10:18 PM
Creation date
12/5/2017 12:54:38 AM
Metadata
Fields
Template:
EHD - Public
ProgramCode
4200/4300 - Liquid Waste/Water Well Permits
RECORD_ID
87-2625
STREET_NUMBER
20031
STREET_NAME
ELLIOTT
STREET_TYPE
RD
City
LOCKEFORD
SITE_LOCATION
20031 ELLIOTT RD
RECEIVED_DATE
06/19/1987
P_LOCATION
MIKE OSBORN
Supplemental fields
FilePath
\MIGRATIONS\E\ELLIOTT\20031\87-2625.PDF
QuestysFileName
87-2625
QuestysRecordID
1730644
QuestysRecordType
12
Tags
EHD - Public
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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL,HEALTH DISTRICT <br /> 1601 E. HAZEL T ON 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. 1862 for welUpump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> Job Address �CL City Lot Size x 0 PM <br /> �S��R —"��..� _ <, Phony • 7Z <br /> Owner's Name FAddress <br /> ContractoRb Address 10004 �z _License Nom Phone <br /> .TYPE OF WELL/PUMP: }__ _,NEW WELL 0w,.. . .._ _WELL REPLACEMENT ❑ DESTRUCTION ❑_ � <br /> PUMP INSTALLATION ❑ 1 SYSTEM REPAIR © OTHER ❑ O <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES a '7]ISPOSAL FLD. PROP. LINE O <br /> FOUNDATION '""A6RiCULTURE WELL . A t 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 /> '�' r❑ Domestic/Privates�A ❑-Gravel'Pack ---❑ Tracy - Type of Casing Specifications _ <br /> M Publica.\ <br /> ; HCl Delta Depth of Grout Seal Type of Grout 1 <br /> 1 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 /> �q iii`"a'.'t b i !•., <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> Depth i Filler Material 18elow 501 �• S •` ' <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I:] REPAIR/ADDITION/ DESTRUCTION I I (No septic system permitted if public sewer is <br /> , / available within 200 feet.) <br /> V <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: 'w Water table depth <br /> SEPTIC TANK ❑ Type/Mfg No. Compartments Z <br /> i <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> t Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ,Vlf No. & Length of lines` - - ` Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> /SEEPAGE PITS l I Depth �� Size ��1 Z A!4!.ti Number c' �'�.s ef'w� v;,t <br /> 'SUMPS lgie Distance to nearest: Well Foundation ,2b�-30� Property Liner.._._.4�40 <br /> 1 DISPOSAL PONDS ❑ <br /> .l hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county Qrdinances, state lavys, and <br /> L rules and regulations of the San Joaquin Local Health District. f11 .''I �,r. "k- <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,,) 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 issued';' shall employ persons subject�to workman's.cbmpensa- <br /> tion laws of California." <br /> The applicant m st call for all equired inspections. Complete drawing on reverse side. J �7 <br /> Signed Title: -_ Date: rd ��✓ <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date `-' ' �` � Area B <br /> Pit or Grout Inspection by bate. Firial Inspection by Date <br /> Additional Comments: � - <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca: 823-7104 ❑ Tr cy 835--&385 <br /> f Applicant- Return all copies to: Environmental Health PeriM7Service,s 1601 E. Hazelton Ave., P.O:9ox 2009, Stk., CA 95201" <br /> EE <br /> INFO <br /> AMOUNT-DUE 1 tdUNT REMITTED CASH RECEIVED BY DATE PERMI7'NO. <br /> + EH 13-24{REV.1/95) <br /> EH 1428 531 <br /> 611 <br /> Y! <br />
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