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4200/4300 - Liquid Waste/Water Well Permits
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90-2213
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Last modified
2/17/2020 12:59:16 AM
Creation date
12/5/2017 2:19:52 AM
Metadata
Fields
Template:
EHD - Public
ProgramCode
4200/4300 - Liquid Waste/Water Well Permits
RECORD_ID
90-2213
STREET_NUMBER
10974
Direction
E
STREET_NAME
FAIRCHILD
City
STOCKTON
SITE_LOCATION
10974 E FAIRCHILD
RECEIVED_DATE
98/23/1990
P_LOCATION
M SATAKE
Supplemental fields
FilePath
\MIGRATIONS\F\FAIRCHILD\10974\90-2213.PDF
QuestysFileName
90-2213
QuestysRecordID
1761912
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 (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. r� <br /> /0 9/ � n ch t"I City C Lot Size e PM <br /> Jot}Address <br /> tr <br /> Owner's Name Address r Phone <br /> Contractor Address o License No. 7�1 Phone 361 <br /> TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT DESTRUCTION <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER LJ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELD OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial /(Open Bottom El Manteca Dia. of Well Excavation Dia. of Well Casing <br /> "Domestic/Private (❑ Gravel Pack ❑ Tracy Type of Casing L_ Specifications <br /> ❑ Public ❑ Other 11 Delta Depth of Grout Seal �n Type of Grout <br /> I 1 Irrigation ')_!_Approx. Depth I I Eastern Surface Seal Installed by�1.�/, d��CN Jin1� E'.5Ce,4_P4! ._ <br /> Repair Work Done ❑ Type of Pump SitQ H.P. 39-4– '-State Work Done <br /> Well Destruction Well Diameter !! <br /> Sealing Material {top 50'1 � <br /> Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION l 1 REPAIR/ADDITION l I DESTRUCTION I I (No septic system permitted if public sewer is Y\ <br /> available within 200 feet.) <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 ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No- & Length of lines Total length/size ' <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth ' Size _ Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS Cl <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." Contractor's hiring or sub-contracting signature <br /> certifies the loll? : "I certify that in the performance of the work for which this permit is issued, 1 shall employ persons subject to workman's compensa- <br /> tion laws of Cal lorni .' <br /> The applict m call for all requi inspection : Complete drawing on revere side. Q <br /> Signed X Title: Date: U —a a- 5,0_ <br /> R�gEPARTMENT USE ONLY <br /> Application Accepted by Date [j 74' Area <br /> Pit or Grout Inspection by Date Final Inspection by Js � Date 3 `� <br /> Additional Comments: S1L J O�L.tMy1 <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 95201 <br /> FEE <br /> INFO AMOUNT DUE AMO NT REMITTED SH RECEIVED BY DATE PERMIT'NO. <br /> FC) <br /> EH <br /> -- 3 <br /> +.EH 13-24(REV.t/tt51 �� O /�- O r 2 <br /> EH 144-2e <br /> i <br />
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