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89-2464
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4200/4300 - Liquid Waste/Water Well Permits
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89-2464
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Last modified
12/30/2019 10:10:53 PM
Creation date
12/5/2017 3:45:49 AM
Metadata
Fields
Template:
EHD - Public
ProgramCode
4200/4300 - Liquid Waste/Water Well Permits
RECORD_ID
89-2464
STREET_NUMBER
4056
Direction
E
STREET_NAME
FOURTH
City
STOCKTON
SITE_LOCATION
4056 E FOURTH STREET
RECEIVED_DATE
10/06/1989
P_LOCATION
MAURO M RIOS
Supplemental fields
FilePath
\MIGRATIONS\F\FOURTH\4056\89-2464.PDF
QuestysFileName
89-2464
QuestysRecordID
1771253
QuestysRecordType
12
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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 well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> Job Addreslr~M6- 4 < J� <br /> City TTJCr��f'�I7Lot Size PM <br /> Owner's Nam _- Address 9 2 <br /> Phone <br /> C o n t r a I 150--'e, Kf Address License No. Phone_ <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 FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL 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 /> Cl Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> FI Public C1 Other �-1 Delta Depth of Grout Seal Type of Grout <br /> I i Irrigation _.-Approx. Depth l I Eastern Surface Seal Installed by - <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done C4C ty <br /> Well Destruction ❑ Well Diameter � Sealing Material (top 50'} <br /> Depth Filler Material (Below 501) _ <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION i I REPAIR/ADDITION i I DESTRUCTIO . 1 (No septic system permitted if public sewer is (� <br /> 7 •. <br /> Installation will serve: Residence_ Commercial_ Other available within 200 feet.} <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 clearest: Well Foundation Property Line <br /> SEEPAGE PITS i 1 Depth Size Number <br /> SUMPS Cl Distance to nearest: Well Foundation Property Line <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 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 subcontracting 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 inspections. Complete drawing on reverse side. <br /> Signed X Title: Q cu efe rr Date: <br /> F. DEPARTMENT USE ONLY <br /> Application Accepted by1a- It —� 1 <br /> Date tea <br /> Pit or Grout Ins � _ <br /> Inspection by Date _ Final Inspection.bf Date <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 D 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 AMOUNT DUE AMOUNT REMITTED CK <br /> INFO CASH RECEIVER BY DATE PERMIT ND. <br /> 15H 13-24 SCE <br /> +. IHEV.1/8 sl <br /> EH 14-26 • ✓� i r �v I I �u�7 <br />
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