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91-1135
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4200/4300 - Liquid Waste/Water Well Permits
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91-1135
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Entry Properties
Last modified
3/16/2020 12:36:35 AM
Creation date
12/5/2017 5:21:08 AM
Metadata
Fields
Template:
EHD - Public
ProgramCode
4200/4300 - Liquid Waste/Water Well Permits
RECORD_ID
91-1135
PE
4380
STREET_NUMBER
6632
Direction
E
STREET_NAME
ACAMPO
STREET_TYPE
RD
City
ACAMPO
SITE_LOCATION
6632 E ACAMPO RD ACAMPO
RECEIVED_DATE
05/16/1991
P_LOCATION
TONY FUSSO
Supplemental fields
FilePath
\MIGRATIONS\A\ACAMPO\6632\91-1135.PDF
QuestysFileName
91-1135
QuestysRecordID
1628721
QuestysRecordType
12
Tags
EHD - Public
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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT pq Y <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 c � ✓ <br /> +�s.1 PERMIT EXPIRES 1 YEAR FROM DATE ISSUEDSAN JoAy <br /> til (Complete in Triplicate) fNVjR�� ����,%111��?�//5 'r <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the wo�l(cvt*jiIy�!ki1#q ;,ljltis 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 Fi' 4 ;'o(oe San Joaquin <br /> Local Health District. �''.Vt ". <br /> Job Address t,>O 3Z F 4&04J!0 City Lot Size PM <br /> Owner's Name V� Address b6' n �. Phone <br /> Contractor r Address Iy�2 ►`�/ License No. 42,l 1_Phone 2 <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 /> F1 Public ❑ Other Ll Delta Depth of Grout Seal Type of Grout <br /> Irrigation .Approx. Dep I Eastern Surface Seal Installed by _ <br /> Repair Work Done L1 Type of Pump . H.P. �Zel A44 State Work Done_ <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION f I REPAIR/ADDITION I I DESTRUCTION I I (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: Number of bedrooms <br /> 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 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 Di§trict. <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 />�f 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 requi d inspections. Complete drawing on reverse side. <br /> Signed X_�_•, C1 Title: 0_Gy�t1 Date: <br /> .�/�_9Z <br /> R DEPARTMENT USE ONLY i G <br /> Application Accepted by AAAA .r. Date 5 t 1 ( Area <br /> Pit or Grout Inspection by Date Final Inspection by T� �arz` 19&J Date <br /> Additional Comments: F/�� 4 f b / A ��/����LS�+�— <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 8233 ❑ Tracy 5-6385 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201FEE .�,�� <br /> CK 9 <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIIT NO. <br /> + EH 13-241REV.1iHs) {.�� _T;:31) <br /> ` - >,' yP J j _ • 1 �1�- <br /> EH 14-26 1 • „`. LQ <br />
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