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89-614
EnvironmentalHealth
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4200/4300 - Liquid Waste/Water Well Permits
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89-614
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Last modified
1/9/2020 10:08:56 PM
Creation date
12/5/2017 5:01:51 AM
Metadata
Fields
Template:
EHD - Public
ProgramCode
4200/4300 - Liquid Waste/Water Well Permits
RECORD_ID
89-614
PE
4373
STREET_NUMBER
705
Direction
S
STREET_NAME
ACACIA
STREET_TYPE
ST
City
RIPON
SITE_LOCATION
705 S ACACIA
RECEIVED_DATE
3/28/1989
P_LOCATION
MAXINE VAN SLYKE
Supplemental fields
FilePath
\MIGRATIONS\A\ACACIA\705\89-614.PDF
QuestysFileName
89-614
QuestysRecordID
1627716
QuestysRecordType
12
Tags
EHD - Public
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APPLICATION FOR PERMIT <br /> t SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> ti <br /> 0 � 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 <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. �I c <br /> Job Address -7 �/ 4CQ u lat City 041 Lot Size PM <br /> Owner's Name Aa)` NV ��I J 'Q.Address �'�f�1 Phone <br /> Contractor rGt/QAar- Address License No. L� ZS —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 /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> M Public F1 Other 171 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 W rk Don,[ <br /> Well Destruction _K_ Well Diameter Sealing Material (top 50' t <br /> Depth D2 Filler Material (Below 501 Krwl-� <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION ( I DESTRUCTION I I (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> i Installation will serve: Residence_ Commercial— Other <br /> Number of living units: Number of bedrooms <br /> V 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 nearest: Well Foundation Property Line <br /> SEEPAGE PITS I I Depth Size _ Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> 1 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 rformance of the work for which this permit is issued,I shall employ persons subject to workman's compensa- <br /> tion lawsof Califo <br /> The applicant ust call for equir i spections. Complete Irawing on reverA side. C� <br /> Signed X Title: Date: <br /> 2� -=�- <br /> / FOR DEPARTMENT USE ONLY <br /> Application Accepted by 4 r�l� � Date i �— Are <br /> Pit or Grout Inspection by Date Final Inspecti Date <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 /> FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. <br /> EH 3-24(REV.rixS) ✓', V6 I�', <br /> EH t4-26 <br />
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