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88-472
EnvironmentalHealth
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BACON ISLAND
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4200/4300 - Liquid Waste/Water Well Permits
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88-472
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Last modified
12/14/2019 10:09:56 PM
Creation date
12/5/2017 8:27:59 AM
Metadata
Fields
Template:
EHD - Public
ProgramCode
4200/4300 - Liquid Waste/Water Well Permits
RECORD_ID
88-472
STREET_NUMBER
18500
STREET_NAME
BACON ISLAND
STREET_TYPE
RD
City
STOCKTON
APN
12904043
SITE_LOCATION
18500 BACON ISLAND RD
RECEIVED_DATE
03/02/1988
P_LOCATION
CCRC FARMS
Supplemental fields
FilePath
\MIGRATIONS\B\BACON ISLAND\18500\88-472.PDF
QuestysFileName
88-472
QuestysRecordID
1655668
QuestysRecordType
12
Tags
EHD - Public
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,1 \ <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT 1 <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA I <br /> Telephone (209) 466-6781 j <br /> PERMIT EXPIRES TYEAR FROM DATE ISSUED l <br /> �•p��_ (Complete in Triplicate) rZ�� btf�0 —C{3 <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 an Joaquin .ordinance No. 9 tar sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. �/ `rr"`,.',*Oe 3 [-1 o <br /> /ra <br /> Job Address .- City/ Lot Size PM <br /> Owner's Name /�_ �64Address g_ ._i Phone <br /> � <br /> Contractor Address License No. <br /> Phone_ <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP IN ILLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TAN SEWER LINES OSAL FLD. PROP, LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS ; <br /> INTENDED USE TYPE OF WELL PR EM AREA�Iii CO UCTION SPECIFICATIONS <br /> ❑ Industrial 111 Open Bottom ❑ Mantec ia. of Well Excavation Dia. of Well Casing <br /> n 3 <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy pe of Casing Specifications <br /> F1 Public ❑ Other fZ D Dept Grout Seal Type of Grout <br /> I I Irrigation Approx, Depth Eastern Surface Se stalled by - <br /> Repair Work Done ❑ Type of Pump I H,P. State Work Done ' <br /> Well Destruction LJ Well Diamet Sealing Material (top 50'1 <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I lEPAIR ADDIT10N)1 DESTRUCTION I I iNo septic system permitted if public sewer is <br /> r available within 200 feet.l <br /> the <br /> Installation will serve: Residence— Commercial . -awl-a <br /> Number of living units: L Number of bedrooms I 01,Character of soil to depth of 3 feet: Water table depth O�o�b C <br /> SEPTIC TANK. 0 Type/Mfg Capacity No. Compartments —� <br /> PWG. TREATMENT PLT. ❑ f X, A- - Method of Disposal <br /> Distance to nearest: X Well /?3 Foundation Property Line __- <br /> LEACHING-LINE ❑ No. & Length of lines `dotal length/size <br /> FILTER BED Distance to nearest: Well AF <br /> I_,Zounclation.,_43 Property Line— — <br /> SEEPAGE PITS l I Depth Size Number <br /> SUMPS D 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: "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 applicant must tali for all required i�cvons. plete drawing on reverse side. <br /> I �J� a <br /> _Signed X - �itle: Date'. <br /> R DEPARTMENT USE ONLY <br /> Application Accepted by Data Area <br /> f Pit or'Grout Inspection by Date Final Inspection by Date <br /> Additional Comments: ar" Sf .i4tA&A -/�� <br /> ❑ Stk 466-6781 YLodi 369-3621 ❑ Manteca 823-71164 ❑ Tracy f 835-W5 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 j, <br /> IFEE NFO AMOUNT DUE AMOUNT REMITTED C SH RECEIVED BY DATE PERMIT NO. J <br /> + EH1&24(REV.iiHsl C`ll jV 4,3Vg //,//{//� �f/ �+ �!/ r /�+` 16 . <br /> EH 14-26 �! L/[/ /I � L. <br />
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