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86-1535
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4200/4300 - Liquid Waste/Water Well Permits
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86-1535
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Last modified
9/3/2019 10:05:36 PM
Creation date
12/5/2017 5:14:31 AM
Metadata
Fields
Template:
EHD - Public
ProgramCode
4200/4300 - Liquid Waste/Water Well Permits
RECORD_ID
86-1535
PE
4211
STREET_NUMBER
3650
Direction
E
STREET_NAME
ACAMPO
STREET_TYPE
RD
City
ACAMPO
SITE_LOCATION
3650 E ACAMPO RD
RECEIVED_DATE
11/25/1986
P_LOCATION
D DELLANAGIORA
Supplemental fields
FilePath
\MIGRATIONS\A\ACAMPO\3650\86-1535.PDF
QuestysFileName
86-1535
QuestysRecordID
1629357
QuestysRecordType
12
Tags
EHD - Public
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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON 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.. <br /> Job Address 36o S0 ,od City Lot Size -26 " PM <br /> IF <br /> Owner's Name `Q Address 13 3 �tp C/1.f71Gc "_I phone 36 /'3,P7-3 <br /> Contractor '� ddress 6S9XI License No. 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 /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <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 501 U <br /> Depth Filler Material (Below 501 Q <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION K'REPAIR/ADDITION ❑ DESTRUCTION ❑ (Nc septic system permitted if public sewer is <br /> available,within 200 feet.) <br /> Installation will serve: Residence f Commercial_ Other w. <br /> Number of living units:A_ Nu bar 6 bedroo s 2-- <br /> Character of soil to a depth of 3 feet: D f% Water table depth 76 f <br /> SEPTIC TANK ❑ Type/Mfg apacity /2n2_ No. Compartments n <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well I-� I Foundation O I Property Line , <br /> LEACHING LINE 9�'_No. & Length of lines ©� Total length/size 0F <br /> FILTER BED ❑ Distance to nearest: ll 1 C�, Foundation z s I <br /> WeProperty Line <br /> SEEPAGE PITS E Doth Size X 10 X 1 c1( Number 21 <br /> SUMPS Distance to nearest: Well 1`0®1 Foundation 70 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 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 applicant must call for all requir inspections. Complete drawing on reverse side. <br /> v[/' <br /> r D W �l <br /> Signed X � Title: Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date Area <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> Additional Comments: 10 <br /> ❑ Stk 466-678114v,„__ ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-M <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 /> + EH1428(REV.iieS) -7 SCJ <br />
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