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87-2717
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BRADFORD
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4200/4300 - Liquid Waste/Water Well Permits
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87-2717
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Last modified
11/13/2019 10:09:19 PM
Creation date
12/5/2017 10:27:34 AM
Metadata
Fields
Template:
EHD - Public
ProgramCode
4200/4300 - Liquid Waste/Water Well Permits
RECORD_ID
87-2717
PE
4222
STREET_NUMBER
2061
STREET_NAME
BRADFORD
City
STOCKTON
SITE_LOCATION
2061 BRADFORD
RECEIVED_DATE
07/17/1987
P_LOCATION
ANTONIO E SOMERA
Supplemental fields
FilePath
\MIGRATIONS\B\BRADFORD\2061\87-2717.PDF
QuestysFileName
87-2717
QuestysRecordID
1667358
QuestysRecordType
12
Tags
EHD - Public
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V <br /> APPLICATION FOR PERMIT <br /> SAN JOAOUIN.LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON 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 3 <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 18M for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> Job Address Z06 8)?Az f-0 kb City �C—?L7�A of Size PM <br /> Owner's Name A/1/041() C �Y" 6AC— 4ddress / l� ��y��' Phone <br /> Contractor / Address 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 FLO. PROP. LINE <br /> t 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 /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P, 4 State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION O REPAIR/ADDITION ❑ DESTRUCTION (No septic system permitted if public sewer is <br /> vailable within 200 feet.) <br /> Installation will serve: Residence T Commercial— Other <br /> r <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;'Disposat, <br /> t Distance to nearest: " Well Foundation Property Line A 1 � <br /> r� <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line y <br /> SEEPAGE PITS ❑ Depth Size Number <br /> SUMPS ❑ Distance to nearest: Well Foundation 'Property Line`r��� " <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. l <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 perfo mance 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 m =!I <br /> re red in ctions. Complete drawing on reverse side. <br /> P�eF t 1 <br /> Signed Title: '�"`� Date: / <br /> � r <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by ,V yAIM Date !7 Area <br /> Pit or Grout Inspection by TT Date °:: Final Inspection by Date <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 /> 4- <br /> • i <br /> FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMITNO. i <br /> INFO CASH) 1 -H-747 <br /> ea l <br /> + EH 1324[REV.i/65) J 1 }}�] �r�2717 <br /> EH 14-28 '"% (J -, . <br />
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