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87-908
EnvironmentalHealth
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4200/4300 - Liquid Waste/Water Well Permits
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87-908
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Last modified
11/27/2019 10:06:53 PM
Creation date
12/5/2017 3:49:41 AM
Metadata
Fields
Template:
EHD - Public
ProgramCode
4200/4300 - Liquid Waste/Water Well Permits
RECORD_ID
87-908
STREET_NUMBER
4834
Direction
E
STREET_NAME
FOURTH
STREET_TYPE
ST
City
STOCKTON
SITE_LOCATION
4834 E FOURTH ST
RECEIVED_DATE
03/24/1987
P_LOCATION
VICTOR & SUSANA
Supplemental fields
FilePath
\MIGRATIONS\F\FOURTH\4834\87-908.PDF
QuestysFileName
87-908
QuestysRecordID
1771249
QuestysRecordType
12
Tags
EHD - Public
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rA APPLICATION FOR PERMIT ' <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL TON AVE.,'STOCKTON, CA „� 1wrC? <br /> Telephone (209) 466-6* <br /> PERMIT EXPIRES"I YEAR FROM DATE ISSUED <br /> M N (Complete in Triplicate), 1.,, <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. 1.862 for well/pump:and the Rules and Regulations of the San Joaquin <br /> Local Health District. "a <br /> �j .A1 'ism` �..'".� F✓`�r' f?'i.. � r;i yi q ' <br /> Job Address i `�` City Lot Size PM <br /> � f <br /> Owner's Name /�/_ �ry� Address 4---— Phone <br /> Contractor <br /> i <br /> "" "�--- Address License No. Phone_ <br /> TYPE OF WELL/PUMP: I� NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> i NSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SIEPTIC TAN SEWER LINES 4` *' DISPOSAL FLO. LINE <br /> FOUNDATION ULTURE WELL ER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM RUCTION SPECIFICATIONS <br /> ❑ Industrial ❑.Open Bottom nteca ""'Dia. of-'Ne - vation-� Dia. of Well Casing <br /> ❑ Domestic/Private <br /> Eli Gravel Pac ❑ Tracy Type of Casing Specifications <br /> j ❑ Public ❑'O ❑ Delta R y Depth of Grout Seal~ Type of Grout <br /> 1 r .�� <br /> i ❑ Irrigation —Approx. Depth ❑ Eastern i Surface Seal Installed by <br /> Repair Work Done Type of Pump i H.P. i r1 ' State Work Done <br /> Well Destruction Cl Well Diameter Sealing Material (top 501 ~ <br /> Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION LlREPAIR/ADDITION 1:1 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: I�p Number of bedrooms <br /> Character of soil to a d p1h.of 3 feet: Water table depth <br /> SEPTIC TANK Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> I Distance to nearest: Well Foundation Property Line <br /> i LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well -Foundation"°`^" 'Property Line <br /> SEEPAGE PITS ❑ i Depth Size r Number <br /> SUMPS ❑ I Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> 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 /> i Home owner or licensed agent's signature certifies the following: "I certify that]n 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." 4 4_4 <br /> The applicant post call for all requir inspe ions. Complete drawing on reverse side. �/ <br /> Signed �' f Title:' Date: U <br /> k ` , <br /> �N FOR DEPARTMENT USE ONLY "Z ., �{ hh <br /> Application Accepted by Date `� �` Area V <br /> 4, <br /> Pit or Grout Inspectio Date Final Inspection by Date <br /> Additional Comments: <br /> i ❑ 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 /> i FEE AMOUNT``D��UE AMOUNT REMITTED C RECEIVED BY' DATE PERMIT'NO. <br /> INFO <br /> + EH 13.24(REV.1/R5)L I <br /> EH 14-28 <br />
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