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90-2576
EnvironmentalHealth
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ALPINE
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4200/4300 - Liquid Waste/Water Well Permits
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90-2576
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Last modified
2/27/2020 10:12:51 PM
Creation date
12/5/2017 6:02:18 AM
Metadata
Fields
Template:
EHD - Public
ProgramCode
4200/4300 - Liquid Waste/Water Well Permits
RECORD_ID
90-2576
PE
4381
STREET_NUMBER
2723
Direction
N
STREET_NAME
ALPINE
STREET_TYPE
RD
City
STOCKTON
SITE_LOCATION
2723 N ALPINE RD STOCKTON
RECEIVED_DATE
09/25/1990
P_LOCATION
EMICKO KANEISHI
Supplemental fields
FilePath
\MIGRATIONS\A\ALPINE\2723\90-2576.PDF
QuestysFileName
90-2576
QuestysRecordID
1640402
QuestysRecordType
12
Tags
EHD - Public
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APPLICATION FOR PERMIt <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA ) y <br /> Telephone (209) 466-6781 ' <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED SEP 2 1 1P1 <br /> (Complete in Triplicate) ENVIRONMENTAL HEALTI H <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the wo{5R4ITe/6EQ plication 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 /> +� t <br /> Job Address d 7 ?—-3 City ' Lot Size PM <br /> Owner's Name 1 I C'ro /1 1/T S!l Address Phone <br /> Contractor '^mss Address 7l0.�3• � . License No 6. 2_37_3 Phone `'9 4 -r <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 /> [_or Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> f'1 Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation _.Approx. Deptp I I Eastern Surface Seal Installed by _ <br /> Repair Work Done ❑ Type of Pump H.P. J State Work Done_ <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 v <br /> Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I l 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 �JJ <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 l 1 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 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 applicantlrlust call for all re uired inspections. Complete drawing on reverse side. <br /> Signed X_T�,� ,� ✓ -.Title: Date: <br /> OR DEPARTMENT USE ONLY Q —G <br /> Application Accepted by Date 7 Z !/y Area <br /> Pit or Grout Inspection by Date Final Inspection by 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 <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH CK V RECEIVED BY DATE PERMIT NO. <br /> + EH 13-24(REV.1/85) <br /> EH 14-26 ��/ Q`- <br />
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