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89-1466
EnvironmentalHealth
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4200/4300 - Liquid Waste/Water Well Permits
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89-1466
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Last modified
12/23/2019 10:03:57 PM
Creation date
12/5/2017 9:23:25 AM
Metadata
Fields
Template:
EHD - Public
ProgramCode
4200/4300 - Liquid Waste/Water Well Permits
RECORD_ID
89-1466
STREET_NUMBER
9945
Direction
W
STREET_NAME
BENSON FERRY
STREET_TYPE
RD
City
THORNTON
APN
00111004
SITE_LOCATION
9945 W BENSON FERRY RD
RECEIVED_DATE
6/21/1989
P_LOCATION
ROBERT MORI
Supplemental fields
FilePath
\MIGRATIONS\B\BENSON FERRY\9945\89-1466.PDF
QuestysFileName
89-1466
QuestysRecordID
1661449
QuestysRecordType
12
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EHD - Public
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FOR PERMIT <br /> APPLICATION +�Q <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT JUIV <br /> 1601 E. HAZELTON AVE., STOCKTON, CA 2 01989 <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 9 YEAR FROM DATE ISSUED �Nr �� <br /> (Complete in Triplicate) SFR 1CP) H <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. 9 2F VV QCjl — 1 t o t0 <br /> Joh Address L City Lot Size '�' PM <br /> Owner's Name h </ F-�"` Address Phone <br /> Contractor Address License No..!LS-7�I/ Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMOIT ❑ 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 /> ❑ Industrial ❑ Open Bottom ❑.Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> M Public El Other ❑ Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation —.Approx. Depth I 1 Eastern_ 5urface Seal Installed by _ <br /> Repair Work Done ❑ Type of Pump H.P. State Work pone Well Destruction ❑ Well Diameter Sealing Material (top 50'i QccJ .gea-..+.¢ ,P ✓mssE04".01 <br /> .� <br /> Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I l REPAIR/ADDITION l I DESTRUCTION E 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 y <br /> SEEPAGE PITS I I Depth Size Number / <br /> SUMPS Ll 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 Di§trict. <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 no <br /> employ any person in such manner as to become subject to workman's compensation laws of Califotnia."Contractor's hiring or sub-contracting signat3 <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 for required i ct ons. Complete drawing on reverse side. {F <br /> Signed X Title: Date: r <br /> FOR DEPARTMENT SE ONLY }�q <br /> Application Accepted by ` Date +�1 - 1 Area <br /> —/ " <br /> Pit or Grout Inspection by Data Final Inspection byDate `7 <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 <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH CK RECEIVED BY DATE PERMIT NO. <br /> +.E+k13-241REV.i/As) <br /> 1� <br /> EH 14-2e !-+gyp Tq`14 <br />
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