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93-0596
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4200/4300 - Liquid Waste/Water Well Permits
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93-0596
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Last modified
5/19/2020 10:03:44 PM
Creation date
12/5/2017 6:06:09 AM
Metadata
Fields
Template:
EHD - Public
ProgramCode
4200/4300 - Liquid Waste/Water Well Permits
RECORD_ID
93-0596
PE
4221
STREET_NUMBER
591
Direction
N
STREET_NAME
ALPINE
STREET_TYPE
RD
City
STOCKTON
SITE_LOCATION
591 N ALPINE RD STOCKTON
RECEIVED_DATE
04/14/1993
P_LOCATION
TOM CONLIN
Supplemental fields
FilePath
\MIGRATIONS\A\ALPINE\591\93-0596.PDF
QuestysFileName
93-0596
QuestysRecordID
1639454
QuestysRecordType
12
Tags
EHD - Public
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APPLICATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> PERMIT 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 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> Job Address 5"1l M°' aLA1Ale City Lot Size/Acreage <br /> Owner's Name /"M `��L�� Address ,7AJA Phone <br /> Contractor_EL Address License No. Phone <br /> TY—PE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER O Monitoring Well <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 /> n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> [I Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications <br /> I'l Public 1:1 Other n Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done U Type of Pump H.P. ___ State Work Done_ <br /> Well Destruction O Well Diameter Sealing Material & Depth <br /> Depth Filler Material & Depth T <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION (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 O 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 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, and <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 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 gnust call for all required inspections. Complete drawing on reverse side. <br /> Signed X �T14nt ( Title: �fAdit�-� Date: <br /> FOR DEPARTMENT USE ONLY A15 <br /> Application Accepted by Date Y Area 2-{ <br /> Pit or Grout Inspection by Date Final Inspection by Date A 3 <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 <br /> FEE <br /> INFO AMOUNT DUE AMOUNT/REMITTED CASH`CK 0 RECEIVED BY �/DATE PERMIT'NO. <br /> . EH 13.24(REV.r i x sl WOO�= d.4, I � �` °� � ^ -05 <br /> EH 11.20 Y <br />
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