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90-1709
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4200/4300 - Liquid Waste/Water Well Permits
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90-1709
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Last modified
2/2/2020 10:12:48 PM
Creation date
12/5/2017 6:09:22 AM
Metadata
Fields
Template:
EHD - Public
ProgramCode
4200/4300 - Liquid Waste/Water Well Permits
RECORD_ID
90-1709
PE
4382
STREET_NUMBER
9726
Direction
N
STREET_NAME
ALPINE
STREET_TYPE
RD
City
STOCKTON
SITE_LOCATION
9726 N ALPINE RD STOCKTON
RECEIVED_DATE
07/05/1990
P_LOCATION
JOHN SCHULER
Supplemental fields
FilePath
\MIGRATIONS\A\ALPINE\9726\90-1709.PDF
QuestysFileName
90-1709
QuestysRecordID
1640682
QuestysRecordType
12
Tags
EHD - Public
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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> �. ENVIRONMENTAL HEALTH DIVISION <br /> 1601 E. HAZELTON AVE. , PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> F PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> �" etc" f, /' (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 Or inance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> a e7 6 14 <br /> Job Address City � Lot Size/Acreage <br /> Owner's Name Address Phone <br /> Contractor Address r 7104 License No. t90 9rPhone — <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION O SYSTEM REPAIR i.' OTHER ❑ 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 O Open Bottom O Manteca Dia. of Well Excavation Dia. of Well Casing <br /> Kbomestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> I'I Public fl Other n Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation Approx. Depth ( 1 Eastern ace Seal Installed by <br /> Repair Work Done 9 Type of Pump �f H.P. State Work Done r <br /> Well Destruction ❑ Well Diameter Sealing Material & Depth <br /> Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I INo 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 11 Depth Size _ Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that 1 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 r > <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: "1 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 applican s call for all required i ctions. omple drawing on rev side. TQ <br /> Signed Title: -_ Kyo s . Date:FOR DEPARTMENT USE ONLY hh <br /> Application Accepted by Date �y Area <br /> Pit or Grout Inspection by Date Final Inspection by S c.{trarfr. DateQ.� <br /> Additional Comments: <br /> Applicant - Return all 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 INFO AMOUNT DUE AMOUNT CASH CASH CK RECEIVED BY DATE PERMIT'NO. <br /> + EH A-2 (REV.1/0115) F F '�7 -C o b— `� <br /> EH;�2a ( ✓ 1 <br />
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