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90-2224
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4200/4300 - Liquid Waste/Water Well Permits
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90-2224
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Last modified
2/17/2020 1:03:54 AM
Creation date
12/5/2017 5:33:24 AM
Metadata
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Template:
EHD - Public
ProgramCode
4200/4300 - Liquid Waste/Water Well Permits
RECORD_ID
90-2224
STREET_NUMBER
9440
STREET_NAME
ALHAMBRA
City
STOCKTON
Supplemental fields
FilePath
\MIGRATIONS\A\ALHAMBRA\9440\90-2224.PDF
QuestysFileName
90-2224
QuestysRecordID
1637237
QuestysRecordType
12
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EHD - Public
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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION ��f�I <br /> 1601 E. HAZELTON AVE. , PHONE (209)468-3420%0�wf% <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> REMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work herein described. This <br /> application is made in Compliance with San Joaquin County Ordinance No. 549 and 1562 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> Job Address Cit of Size/Acreage <br /> Owner's Name Address _(_��> �pa+ • Phone <br /> /�� G57 <br /> ConlraClor. +l� Address - R40...d&x 19 Z 7 icense No./bZ 3 73_Phone <br /> ContraClorb <br /> TYPE OF WELL/PUMP: ISIEW WELL ❑ WELL REPLACEMENT [Or DESTRUCTION Out of Service Well ❑ <br /> PUMP INSTALLATION alo-' SYSTEM REPAY ❑ OTHE5 ❑ Monitoring Well ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK ZOO SEWER LINES ZM DISPOSAL FLO.14W PROP. LINE <br /> aG0 <br /> FOUNDATION -- -- 1 AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> n Industrial ❑��� OOp�pen Bottom C1 Manteca Dia. of Well Excavation Dia. of Weil Casing <br /> [WIS"mestic/Private I -151avel Pack ❑ Tracy Type of Casing pile Specifications <br /> I') Public f-7 Other 171 Delta Depth of Grout Seal pe of Grout og <br /> I ! Irrigation __ .Approx. Dept l I Eastern Surface Seal Installed by - <br /> Repair Work Done Lfl Type of Pump 14%0 H.P. _3 — State Work Done a <br /> Well Destruction U-Well Diameter ._ Sealing Material & Depth <br /> Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION i I DESTRUCTION I 1 (No septic system permitted if public sewer is <br /> available within 200 feet.l <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 O Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> r� <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS LI 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, ander <br /> rules and regulations of the San Joaquin County <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 pars manner as to become subject to workman's compensation taws of California." Contractor's hiring or sub-contracting signature <br /> certifies the f owing: "I c it that ingt ;or ceof the work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws California." <br /> The appl! ant mu , all re o plate drawing o e i <br /> Signed !� Title: •` Date: f-zo r <br /> eq <br /> FOR EPARTMENT USE ONLY (� ^ �y� <br /> Application Accepted by Date �]�d�� [ — Area <br /> Pit or Grout Inspection)bFinalDateInspection by Date <br /> Additional Comments: W K.�"�^ <br /> IF <br /> Applicant - Return dl,copies to: San Joaquin County Public Health <br /> Services, Environmental Health Permit/Services <br /> 1601 E. Hazelton Ave.. P 0 Box 2009, Stockton, CA 95201 <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH CK RECEIVED BY DATE PERMiT'.NO. <br /> a fH 1,- TREY.riear 'Fa <br /> - /} <br />
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