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87-1519
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4200/4300 - Liquid Waste/Water Well Permits
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87-1519
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Last modified
9/13/2019 9:58:15 AM
Creation date
12/5/2017 3:24:59 AM
Metadata
Fields
Template:
EHD - Public
ProgramCode
4200/4300 - Liquid Waste/Water Well Permits
RECORD_ID
87-1519
STREET_NUMBER
2619
STREET_NAME
FLORIDA
STREET_TYPE
AVE
City
STOCKTON
SITE_LOCATION
2619 FLORIDA AVE
RECEIVED_DATE
04/22/1987
P_LOCATION
R L PATZER
Supplemental fields
FilePath
\MIGRATIONS\F\FLORIDA\2619\87-1519.PDF
QuestysFileName
87-1519
QuestysRecordID
1768829
QuestysRecordType
12
Tags
EHD - Public
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APPLICATION FOR PERMIT <br /> ... SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL ION AVE., STOCKTON, CA <br /> Telephone (209) 466- 6781 <br /> t 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. <br /> y -y • r <br /> Job Address UE <br /> City Lot Size SD X 7'e v PM <br /> Owner's Name A7-z Ei2-- Address DA Phone <br /> Contractor_ -4-o y/�7.) _Address GOr'AI, 1-1,L4/A Al 4-fl6 License_No. ! Y_ t <br /> ne <br /> TYPE OF WELL/PUMP: NEW WELL 0 WELL REPLACEMENT ❑ DESTRUC <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR El OT <br /> DISTANCE TO NEAREST: SEPTIC TANK" SEWER LINES DISPOSAL FLD. E <br /> FO DATION AGRICULTURE WELL OTHER WELL PS <br /> INTENDED USE TYPEOF LL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> LJ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ElDomestic/Private F-1Gravel Pack acy Type of Casing ) Specifications <br /> ❑ Public ❑ Other Type of Grout <br /> '. ❑ Delta Depth of Grout Seal <br /> 1-1 Ir _�pprox. Depth ❑ Eastern Su nstalled by <br /> Repair Work Done ❑ Type of Pump H.P. <br /> ? Sta a Work Done <br /> Well Destruction i ❑ Well Diameter Sealing Material (top 50') <br /> } a Depth Filler Material (Below 50'1, <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION (No septic system permitted if public sewer is <br /> t <,, available within 200 feet.) <br /> � <br /> Installation will serve- Resid nee Commercial, Other ' ; `e <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: I Water table depth <br /> SEPTIC TANK F1 Type/Mfg �- Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑: r Y Method of Disposal <br /> Distance to nearest, i Weil Foundation-'Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑; Distance to nearest: 6 Well Foundation Property Line <br /> v , <br /> SEEPAGE PITS ❑ Depth Size Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ r: <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 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 for all required insp ons. Complete drawing on reverse side. I <br /> Signed <br /> Title: <br /> _ Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date -7, Z Area <br /> Pit or Grout Inspection b Date Final Inspection by pater <br /> . Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Mante 823-7104 - ❑ Tracy 6365 �U G/LJ, <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Bax 2009, Stk., CA 95201 -'QI "� <br /> FEE C RECEIVED AMOUNT DUE AMOUNT REMITTED (, <br /> INFO SH BY DATE PERMIT NO. <br /> + EH 13-24IHEV.-i/N5l <br />
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