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88-1489
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4200/4300 - Liquid Waste/Water Well Permits
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88-1489
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Last modified
11/30/2019 10:07:43 PM
Creation date
12/5/2017 4:27:48 AM
Metadata
Fields
Template:
EHD - Public
ProgramCode
4200/4300 - Liquid Waste/Water Well Permits
RECORD_ID
88-1489
STREET_NUMBER
379
STREET_NAME
FRENCH CAMP
STREET_TYPE
RD
City
FRENCH CAMP
SITE_LOCATION
379 FRENCH CAMP RD
RECEIVED_DATE
06/10/1988
P_LOCATION
BARBARA HAYASHINO
Supplemental fields
FilePath
\MIGRATIONS\F\FRENCH CAMP\379\88-1489.PDF
QuestysFileName
88-1489
QuestysRecordID
1775597
QuestysRecordType
12
Tags
EHD - Public
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APPLICATION FOR PERMIT ��a <br /> SAN .fOAQUIN LOCAL HEALTH DISTRICT <br /> V� <br /> 1601 E. HAZELTON AVE., STOCKTON, CA O �$B <br /> Telephone (209) 466-6781 a>�1� <br /> PERMIT EXPIRES TYEAR FROM DATE ISSUED ��pME`��AR�j� <br /> (Complete in Triplicate) 104l RM��J5E <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the workein 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 Address � �e��/�I ��'� /�-�'/ Ciry7/le f/!- at Size PM <br /> �"7 d2�1 <br /> Owner's Name a ��O Address G Phone <br /> Contractor s{�>Pi C2 Address v License No 2 Phone <br /> TYPE OF!WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION 17SYSTEM REPAIR ;l( OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> t FOUNDATION AGRICULTURE WELL - OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑—n `Tial ❑ Open Bottom 11 Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ,ZDome'stic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> f'1 Publicn Other + F7 Delta Depth of Grout Seal Type of Grout <br /> i <br /> I Eastern Surface Seal Installed by <br /> 1.1 Irrigation --Approx. Dept I <br /> Repair Work Done E71 Type of Pumpu� H.P. State Work Done <br /> Well Destruction ❑ Well Diameter 6 Sealing Material Itop 501 <br /> I Depth Filler Material I6elow 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/.ADDITION I 1 DESTRUCTION I 1 INo 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 /> Aaracter of soil to a derpth of 3 feet: Water table depth <br /> SEPTIC TANK EIType/Mfg i 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 lBED ❑ Distance to nearest: Well Foundation Property Line <br /> i <br /> SEEPAGE PITS C I Depth Size Number <br /> SUMPS Ll 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 sub-contracting signature <br /> • certifieslthe 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 law's of California." <br /> i The applicant m t I r all required i pections. Complete drawing on reverse side. <br /> 1�_� . <br /> Signe �X �`rl Title. .7�a/Gf///�i'•c/DSC rL- Date:FOR DEPAR�MENT USE ONLY <br /> Application Accepted by Date Are <br /> I Iate ff <br /> Pit or Grout Inspection by Date Final Inspection by 3- <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.O. Box 2009, Stk., CA 95201 <br /> i FEE I AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE f ERMIT�N0. <br /> INFO CASH <br /> +.EH 13-241REVI.I�K 51 ✓ S' jo <br /> } EH 1428 <br />
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