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4200/4300 - Liquid Waste/Water Well Permits
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90-3056
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Last modified
3/2/2020 2:34:28 AM
Creation date
12/5/2017 10:02:28 AM
Metadata
Fields
Template:
EHD - Public
ProgramCode
4200/4300 - Liquid Waste/Water Well Permits
RECORD_ID
90-3056
PE
4211
STREET_NUMBER
37651
Direction
S
STREET_NAME
BIRD
STREET_TYPE
RD
City
TRACY
SITE_LOCATION
37651 S BIRD RD
RECEIVED_DATE
11/15/1990
P_LOCATION
VON CRITES
Supplemental fields
FilePath
\MIGRATIONS\B\BIRD\37651\90-3056.PDF
QuestysFileName
90-3056
QuestysRecordID
1664688
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 /> IN Telephone (209) 466-6781 <br /> PERMIT EXPIRES 'I'YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby made to the San Joaquin Loca�1 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 City GV Lot Size PM <br /> t _ <br /> Address Phone <br /> Owner's Name ��,��yy <br /> Contractor .�/�� Addrl�ss_R��-_,._ � �d License No1!/Ja5= Phone ✓ � — <br /> TYPE OF WELL/PUMP: NEW WELL �❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION 17 SYSTEM REPAIR ❑ OTHER ❑ ' <br /> DISTANCE TO NEAREST: SEPTIC TANK I� SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUNIPS <br /> INTENDED USE TYPi= OF WELL PROBLEM AREA CQNSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom 11 Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> I <br /> j [`1 Public F] Other n Delta Depth of Grout Sea! Type of Grout _ <br /> li I I Irrigation _.-Approx. Depth 1�1 Eastern Surface Seal Installed by ( <br /> �R`epair Work Done ❑ —Type of Pump H.P. State Work Done <br /> Well Destruction El Well Diameter Sealing Material (top 50'1 . <br /> Depth j1. Filler Material(Below 50'I <br /> j TYPE OF SEPTIC WORK; NEW INSTALLATION REPAIR/ADDITION I I DESTRUCTION I i Wo septic system permitted if public sewer is <br /> j available within 200 feet.) <br /> Installation will serve: ResidenceCommercial Other <br /> i ''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 Tf Capacity No. Compartments j <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: WellFoundationl'7� Property.Line <br /> LEACHING LINE No. & Length of lines /--7- Tota! length/sized 1 <br /> FILTER BED ❑ Distance to nearest: �' WeII�f' Foundation ��i7}/�'r Property Line <br /> SEEPAGE PITS' l 1 Depth Size Number <br /> SUMPS "fR" Distance to nearestd Wel > oundation �� 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,Dli 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 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, 1,shall'employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant must call for*,requiredL inspections) Complete drawing on reverse side. <br /> Signed X I! 'Title: ' = Date: - <br /> " "h FOR DEPARTMENT USE ONLY <br /> Application'Accepted by Date"" <br /> ate. L p Area <br /> Pit or Grout Inspection by Date Final Inspection by Data�O <br /> Additional Comments: f'6 II <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 0 Manteca 823-7104 ❑ Tracy 835-6385 t <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009,,Stk., CA 95201 <br /> II `r <br /> FEE AMOUNT Dt1E AMOUNT REMITTED CK RECEIVED BY' DATE PERMIT NO. <br /> INFO ` CASH <br /> "�^ <br /> ♦,EH13-241REv.M45J !� v .� i- +'q,� <br /> EH 14-2a 1l 366" (J <br /> kl , T } i <br /> _ I h9;. , <br />
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