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87-2871
EnvironmentalHealth
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ESCALON BELLOTA
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13553
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4200/4300 - Liquid Waste/Water Well Permits
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87-2871
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Last modified
11/14/2019 10:23:36 PM
Creation date
12/5/2017 1:23:44 AM
Metadata
Fields
Template:
EHD - Public
ProgramCode
4200/4300 - Liquid Waste/Water Well Permits
RECORD_ID
87-2871
STREET_NUMBER
13553
STREET_NAME
ESCALON BELLOTA
City
ESCALON
SITE_LOCATION
13553 ESCALON BELLOTA
RECEIVED_DATE
07/17/1987
P_LOCATION
RICK WELLS
Supplemental fields
FilePath
\MIGRATIONS\E\ESCALON BELLOTA\13553\87-2871.PDF
QuestysFileName
87-2871
QuestysRecordID
1737809
QuestysRecordType
12
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EHD - Public
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APPLICATION.,FOR PERMIT Y '� <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone 1209! 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. Tr, No <br /> (/� -; /1 �� City Lot Size19� PM <br /> Job Address i 1 <br /> Y� Ay`+ Address — a �I S Phone _ <br /> Owner's Name i�� <br /> Contractor / Address / 1� License No, (y Phonal <br /> TYPE OF WELL/PUMP: t . NEW WELL ❑ x WELL REPLACEMENT [IDESTRUCTION 1-1 <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> r FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca s Dia. of Well Excavation Dia. of V4 ell Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy �,Type of Casing Specifications <br /> ❑ Public ❑ Other O'Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by Q <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> 1 . available within 200 feet.l <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 LlType/Mfg Capacity No. Compartments �— <br /> PKG. TREATMENT PLT. ❑ $ - / L / / Method of Disposal <br /> Distance to nearest: Well Foundation / Property Line <br /> f LEACHING LINE �. No. & Length of lines " Tot �iengthlsize <br /> FILTER BED ❑ Distance to nearest Well Foundation Property Line <br /> SEEPAGE PITS ❑ Depth Size �-- Number 2— <br /> 1 f <br /> SUMPS ❑ . Distance to nearest: Well IA00,7 Foundation•�LS�=► Property Line <br /> DISPOSAL PONDS Cl <br /> i 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 persona subject to workman's compensa t <br /> tion laws of California e <br /> � r' <br /> The applicant mu call for all required inspect' ns. complete dr ing on reverse side:, <br /> Signed X I , Title: G",ad Z � Date: <br /> FOR DEPARTMENT USE ONLY <br /> fApplication Accepted by Date Area <br /> -72 <br /> +; Pit or Grout Inspection by Y Date > i Final Inspection by Date <br /> Ab <br /> t -N V 17 <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.Q. Box 2009, Stk., CA 95201FEE ` <br /> CK 0 <br /> INFO <br /> AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMITNO. <br /> + EH 13-24(REV,i <br /> EH 14.25 - ... <br />
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