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84-224
EnvironmentalHealth
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BENJAMIN HOLT
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4200/4300 - Liquid Waste/Water Well Permits
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84-224
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Last modified
8/16/2019 7:11:57 PM
Creation date
12/5/2017 9:20:02 AM
Metadata
Fields
Template:
EHD - Public
ProgramCode
4200/4300 - Liquid Waste/Water Well Permits
RECORD_ID
84-224
STREET_NUMBER
1000
Direction
W
STREET_NAME
BENJAMIN HOLT
City
STOCKTON
APN
09741073
SITE_LOCATION
1000 W BENJAMIN HOLT
RECEIVED_DATE
03/05/1984
P_LOCATION
S J C
Supplemental fields
FilePath
\MIGRATIONS\B\BENJAMIN HOLT\1000\84-224.PDF
QuestysFileName
84-224
QuestysRecordID
1661152
QuestysRecordType
12
Tags
EHD - Public
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APPLICATION FOR PERMIT <br /> SAN JOAQUiN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT N0. <br /> Telephone (209) 466-6781- DATE ISSUED <br /> PERMIT EXPIRES 1 YEAR FROM-DATE ISSUED <br /> _ (Complete in Triplicate) _ <br /> Application -is herebymadeto the San Joaquin Local Health District for a'permit to construct and/or install the work herein � <br /> described. This application is made in compliance with San Joaquin County,Clfdinance Na. 549 far sewage or No. 1862 for well pump <br /> and the Rules and egulatf rs f the San quin Local health Di�ftraiSyiY6 <br /> - BEe �'sLt �rNe2 L1110, <br /> rSLbdiYitJsiCobnLName. <br /> ,lob Address h , P ne V <br /> Owner's Name —To e, k ress <br /> Phone <br /> Contractor's Name <br /> License No. III <br /> DESTRUCTION <br /> NEW WELL WELL REPLACEMENT 0 ❑ <br /> TYPE OF WELL WORK. Q �,{ OTHER <br /> PUMP INSTALLATION SYSTEM REPAIR ll� a PROP. LINE <br /> # � SEWER LINES DISPOSAL FL➢. <br /> DISTANCE TO NEAREST: SEPTIC TANK + PITS/SUMPS 1 <br /> FOUNDATION <br /> AGRICULTURE WELL N OTHER WELL <br /> e CONSTRUCTION SPECIFICATIONS <br /> y J INTENDED USE TYPE OF WELL PROBLEM AREA , <br /> U Open Bottom [] Manteca i <br /> Dia. of Well Excavation <br /> j j Industrial <br /> Trac Dia. of Well Casing $— <br /> U <br /> Domestic/Private �fGravel Pack [� y ; <br /> public [i Other Delta : Type of Casing <br /> Irrigation / te 11 <br /> Approx. Eastern Spec i fi cationsIA11Cr <br /> Depth D pth of Grout Seal <br /> Cathodic Protection ~ <br />'i Geophysical �j Type of Grout <br /> Other .4 Surface Seal Installed by �����e�tr 3�a-L �ttK C <br /> Repair W rk Done �j Type of Pump H.P. <br /> ' .State Work Done <br /> ' Sealing Material ,(top. 50') 11 <br /> Well Destruction U Well Diameter <br /> e <br /> ;. Depth Filler Material (Bel'ow 50'} �A r <br /> 4 REPAI <br /> TR/A�➢1TIDN. I (No septic tank or seepage pi <br /> tPermitted t1 public sewer is <br /> YPE�OF�SEEPTIC_WORKLI,: NEW INSTALLATION _ available vtth7n 200 feet�}�-r'"'" <br /> F Commercial Other W <br /> Installation will serve: Residence _ — Lot size �1 <br /> Number of living units: Number of bedrooms Water table depth <br /> + Character of soil to a depth of'3 feet: No. Compartments <br /> Capacity <br /> (SEPTIC TANK EJ Type/Mfg Capacity Method of Disposal <br /> 'EKG. TREATMENT PLT. [] Type/Mfg Property <br /> Line Q <br /> W. Foundation P <br /> SEWAGE SYSTEM Distance to nearest: Well tII f y <br /> 4 DESTRUCTION I ` <br /> LEACHING LINE ❑ No. & ,Length of lines " <br /> Total length/size <br /> ' Distance to nearest: Well ✓ Foundation <br /> Property Line <br /> FILTER'BED I� <br /> e th Size -_, Number <br /> D <br /> SEEPAGE PITS [� p Foation Property Line <br /> Distance to nearest: Well <br /> SUMPS EI <br /> DISPOSAL PONDS ❑ ( r <br /> pared this application and that the work will be done in accordance with Sa <br /> I hereby certify that I have pren Joaquin county <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. ance of <br /> Home owner or licensed agent' signature certifies the following; t4.3 <br /> certifysthjtinect tthe perfo h compensatlionwlaws fof California." <br /> permit is issued, s 11 n p y y,P rtif t a performance of the work for which <br /> Contractor's hi i su o rotten ure ter i s• V21� 1oll17{� la� rnia." <br /> this permit i i� I rsons s�bje f <br /> F The applicant m f a 1 d inspections. Completdawin on re-terse side. s <br /> 4 � Date: J� <br /> Title: y <br /> . Signed X <br /> -✓FOR PARTMENT USE ONLY' Area Stk 466-6787 <br /> AP plica n cepted Lodi 369-3621 <br /> Additional Comments: Date Manteca 823-7104 <br /> � �-� <br /> pit or Grout Inspecali?� <br /> pate q L7 Tracy 835-6385 <br /> Final Inspection by <br /> i Applicant - Return all cap ronmental Health Permit/Services 1661 E. Hazelton Ave., P.O. box 2009, Stk., CA 95201 <br /> FEE BASE AMOUNT: DUE AMOUNT REMITTED <br /> RECEIVED BY DATE PERMIT NO. <br /> INFO —� W <br /> _5 Of <br /> F . <br /> EH 13-24 REV. 10/$2 <br /> 14-26 <br />
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