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84-597
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4200/4300 - Liquid Waste/Water Well Permits
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84-597
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Last modified
8/17/2019 10:10:51 PM
Creation date
12/5/2017 3:46:53 AM
Metadata
Fields
Template:
EHD - Public
ProgramCode
4200/4300 - Liquid Waste/Water Well Permits
RECORD_ID
84-597
STREET_NUMBER
4248
Direction
E
STREET_NAME
FOURTH
STREET_TYPE
STREET
City
STOCKTON
SITE_LOCATION
4248 E FOURTH STREET
RECEIVED_DATE
05/15/1984
P_LOCATION
MICHAEL HURTADO
Supplemental fields
FilePath
\MIGRATIONS\F\FOURTH\4248\84-597.PDF
QuestysFileName
84-597
QuestysRecordID
1771362
QuestysRecordType
12
Tags
EHD - Public
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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON 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 . F <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 Address y� Lot Size em O X Z DD PM -� <br /> Owner's Name/`3�/Cf�1�f( /1. �/��� Address -5 � Phone <br /> Contractor's Name ^42 R/M11' 2f S a S - License No. �S`7� 3'[3 Phone D 7 <br /> TYPE OF WELL/-PUMR:_ --.NEW-WELL_El WELL-REPLACEMENT-El — „DESTRUCTION.❑.._:r <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 /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy __Type of Casing ' Specificatlons <br /> ❑ Public ❑ Other . ❑ Delta Depth of Grout Seal Type of Grout I-• <br /> ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by )!`.- <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done' � <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50') . <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 /> ! 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: • T C -1 `°' Water table depth <br /> SEPTIC TANK 'II'Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line ' <br /> LEACHING LINE El No. & Length of lines -�+� r Total length/size <br /> FILTER BED ❑ Distance to nearest: Well AIA Foundation /0 � Property Line <br /> SEEPAGE PITS Depth �� Size :r&'r'� Number J <br /> SUMPS ❑ Distance to nearest: Well ;/L/A" Foundation 6V 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 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 applican call for all requiredininspection�s. Complete drawing on reverse side. <br /> Signed � � ��1� Title: Date: f <br /> i <br /> Application-Accepted by - F DEPARTMENT USE ONLY <br /> -------- -Date --� - Area--- <br /> Pit or Grout Inspection byO1 i.--Arti�J�—�1s nate S t��`i Final Inspection by C - �.�. Date d �� <br /> '7; rt ft4 <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 95201 <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH CK RECEIVED 9Y DATEp� �P[E�RMIT`NO. <br /> + EH 1324{REV.10/831 45 <br /> EH 14-26 <br />
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