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87-2373
EnvironmentalHealth
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4200/4300 - Liquid Waste/Water Well Permits
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87-2373
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Last modified
11/9/2019 10:07:47 PM
Creation date
12/5/2017 6:09:19 AM
Metadata
Fields
Template:
EHD - Public
ProgramCode
4200/4300 - Liquid Waste/Water Well Permits
RECORD_ID
87-2373
PE
4382
STREET_NUMBER
967
Direction
N
STREET_NAME
ALPINE
STREET_TYPE
RD
City
STOCKTON
SITE_LOCATION
967 N ALPINE RD STOCKTON
RECEIVED_DATE
06/17/1987
P_LOCATION
RAY SCHENONE
Supplemental fields
FilePath
\MIGRATIONS\A\ALPINE\967\87-2373.PDF
QuestysFileName
87-2373
QuestysRecordID
1640021
QuestysRecordType
12
Tags
EHD - Public
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'?)C6V APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 JUN 1 1 ��87 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED NTAL HEALTH <br /> (Complete in Triplicate) EN (M /SERVICES <br /> Application is hereby made to the San Joaquin.Local Health District for a permit to construct and/or install the work he escribed.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 City�J.._ Lot Size PM <br /> Owner's Name Address � �T, ®, Phone <br /> Contractor �i11fE' Address License No. A*/ Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION YK SYSTEM REPAIR Jak, 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 /> P—Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> FI Public n Other F] Delta Depth of Grout Seal Type of Grout _ <br /> I I Irrigation A_Approx. Depth I Eastern Surface Seal Installed by - <br /> Repair Work Done ❑ Type of Pump ppy --I+.P. S—� State Work Done <br /> Well Destruction El Well Diameter IQ Sealing Material (top 501 <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 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 /> _v <br /> SEEPAGE PITS I I Depth Size Number <br /> SUMPS Ll Distance to nearest: Well Foundation Property Line J <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 su manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature <br /> certifies the following: ' c i 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 i` <br /> The applicant must o all squire in ions. Complete drawing on reverse sid <br /> Signed X Title: E, Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date Area [r <br /> Pit or Grout ivxpection b Date Final Inspection by Date T�b <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 AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. <br /> INFO . ,�� CASH <br /> � �7 <br /> + EH 13-24(REV.I i n 5) 2> <br /> EH 14-26 <br />
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