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89-186
EnvironmentalHealth
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ATKINSON
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4200/4300 - Liquid Waste/Water Well Permits
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89-186
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Last modified
12/26/2019 10:08:57 PM
Creation date
12/5/2017 7:26:06 AM
Metadata
Fields
Template:
EHD - Public
ProgramCode
4200/4300 - Liquid Waste/Water Well Permits
RECORD_ID
89-186
PE
4210
STREET_NUMBER
12765
STREET_NAME
ATKINSON
STREET_TYPE
RD
City
LODI
SITE_LOCATION
12765 ATKINSON RD LODI
RECEIVED_DATE
01/27/1989
P_LOCATION
MARVIN LUTZ
Supplemental fields
FilePath
\MIGRATIONS\A\ATKINSON\12765\89-186.PDF
QuestysFileName
89-186
QuestysRecordID
1649444
QuestysRecordType
12
Tags
EHD - Public
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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described.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 /> r � <br /> Job Address / 7'.��,✓�d City ! Lot Size PM <br /> Owner's Name —A411 4de L// viz Address _O T�� Phone <br /> ' Contractor Address d > License No, Phone <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 /> El Industrial ❑ Open Bottom El Manteca Dia. of Well Excavation Dia. of Well Casing <br /> El Domestic/Private ❑ Gravel Pack ElTracy Type of Casing Specifications <br /> f'1 Public ❑ Other ❑ 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 ❑ Type of Pump H.P._ State Work Done _ <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50') <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 1 1 REPAIR/ADDITION DESTRUCTION I I (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence-k:"'Commercial_ Other <br /> Number of living units: --/— Number of bedrooms _ <br /> Character of soil to a depth of 3 feet: �a4 �'� Water table depth <br /> SEPTIC TANK ElType/Mfg Capacity lllrU No. Compartments td <br /> PKG. TREATMENT PLT. El --r7- Method of Disposal <br /> Distance to nearest: Well Foundation ld Property Line yb <br /> LEACHING LINE �❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Wel_ Foundation Property Line <br /> SEEPAGE PITS I I Depth Size Number <br /> SUMPS Cl Distance to nearesti' Wel( Foundation„ Property Line <br /> DISPOSAL PONDS ❑ <br /> 1 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 applicant must call fy all relp d inspections. Complete drawing on reverse side. <br /> Signed X�� 6 -�-/2�'E-� — Title: Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by D to Area �- <br /> Pit or Grout Inspectio by Date Final Inspection by / Date <br /> - F <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 5-6385 OU�r <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 CASH RECEIVED BY DATE PERMIT NO. <br /> +.EH 13.24(RE/.1/x s) INFO /O� � <br /> EH 14.26 / I I <br />
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