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93-0994
EnvironmentalHealth
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FREWERT
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4200/4300 - Liquid Waste/Water Well Permits
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93-0994
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Entry Properties
Last modified
5/20/2020 10:18:31 PM
Creation date
12/5/2017 4:41:38 AM
Metadata
Fields
Template:
EHD - Public
ProgramCode
4200/4300 - Liquid Waste/Water Well Permits
RECORD_ID
93-0994
STREET_NUMBER
770
Direction
W
STREET_NAME
FREWERT
STREET_TYPE
RD
City
LATHROP
SITE_LOCATION
770 W FREWERT RD
RECEIVED_DATE
06/01/1993
P_LOCATION
Y TAKASHIRO
Supplemental fields
FilePath
\MIGRATIONS\F\FREWERT\770\93-0994.PDF
QuestysFileName
93-0994
QuestysRecordID
1776817
QuestysRecordType
12
Tags
EHD - Public
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APPLICATION FOR PERMIT <br /> c <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ' ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> I P O BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 1 Y FR M DATE ISSU <br /> .1 (Complete in Triplicate) <br /> e to Ban Joaquin County for a permit to construct and/or install the work herein described.,, This <br /> Application is hereby mad <br /> application is made in compliance xith San Joaquin County Ordinance No. 549 and 1862.and the Rules and Regulations of San ` <br /> Joaquin County Public Health Beivices. <br /> /e�ko,5�r 2D City <br /> Job Address 77a ju Lot size/Acreage <br /> Via-*-e Phone <br /> Owner's Name �QSl2 Address <br /> Afa�c��RT 9Sal� . ��� <br /> CoPhone S ContractoraContractor y� Woo Address License Noi <br /> TYPE OF WELLlPUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑ryOut of Service Well Ll <br /> PUMP INSTALLATiON ❑ SYSTEM REPAIR ElOTHER ❑ Monitoring Well ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES _ DISPOSAL FLD.— PROP, LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS i <br /> INTENDED USE TYPE OF WELL PROBLEM AREA - CONSTRUCTION-SPECIFICATIONS =- Dia. of Well Casing <br /> I-) Industrial ❑ Open Bottom EI Manteca Dia. of Well Excavation F <br /> Type of Casing_ Specifications <br /> C.1 Domestic/Private Cl Gravel Pack 0 Tracy Type of Grout <br /> 1'1 Public 1:1 Other n Delta Depth of Grout Seal <br /> I I Irrigation —Approx. Depth I I Eastern Surface goal installed by F. <br /> Repair Work Done U Type of Pump H.P• State Work Done <br /> Sealing Material.i Depth <br /> Well Destruction ❑ Well Diameter Piller Material i Depth ¢ <br /> Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION Al REPAIR/ADDITION{ I DESTRUCTION I I INailableO septtic system <br /> ithin 200 feat�lsd if public sower is <br /> Installation will serve: Residence J Commercial Other <br /> Number of firing units: ---J- Number of bedrooms L r <br /> Character of soil to a depth of 3 feet: :&-dA".g> _ Water table depth <br /> SEPTIC TANK ❑ Type/Mfg <br /> y <br /> A q-L CapacitNo. CompartmentsZ <br /> _+ Method of Disposal <br /> PKG. TREATMENT PLT. 13 ` <br /> ' <br /> Distance to nearest: Well I&V _ Foundation '� _ Property Line <br /> LEACHING LINE 0 No. 6 Length of lines SO r — Total length/size - <br /> FILTER BED ❑ Distance to nearest: Well-LO-C-94-- Foundation Property Line - - <br /> Number <br /> SEEPAGE PITS I i Depth Size <br /> 1 <br /> t SUMPS LI Distance to 1140f"t: Wall Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> I I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, stere laws, an <br /> f rules and regulations of the San Joaquin County <br /> I Home owner or licensed agent's'signature certifies the following:Wil-certify that in the performance rn the work for which this permit is issued;I shall net <br /> employ any person in such manner as to bscorina subjeta to workman's compensation 4vn ss ed,California." Contractor's hiring c sub contracting signature <br /> certifies the following: "I certify that in the psrtormance of the work for which this permit is issued,1 shall employ persons subject to workman's compensa- <br /> tion laws of California." 1t <br /> The applicant must call for all required inapsctions. Complete drawing on reverse side. <br /> Signed X Title: d2a�, Date: <br /> F EPAR T U <br /> / ,,Area <br /> � r✓" <br /> Application Accepted by Date ' <br /> Pit or Grout Inspection by Date .- Final Inspection b Date f <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services u <br /> t 445 N San Joaquin, P O Box 2009, Stkn, GA 95201 <br /> a FEE K RECEIVED BY DATE PERMIT-NO. '{ <br /> I <br /> INFO AMOUNT DUE AMOUNT REMITTED <br /> 1l 0 <br /> • EM 13le 1 <br /> EM 11.2s <br />
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