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87-2621
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ADELBERT
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2016
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4200/4300 - Liquid Waste/Water Well Permits
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87-2621
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Last modified
11/13/2019 10:11:40 PM
Creation date
3/20/2018 10:31:58 AM
Metadata
Fields
Template:
EHD - Public
ProgramCode
4200/4300 - Liquid Waste/Water Well Permits
RECORD_ID
87-2621
PE
4221
STREET_NUMBER
2016
Direction
S
STREET_NAME
ADELBERT
City
STOCKTON
SITE_LOCATION
2016 S ADELBERT STOCKTON
RECEIVED_DATE
7/13/1987
P_LOCATION
AL PORSCH
Supplemental fields
FilePath
\MIGRATIONS\A\ADELBERT\2016\87-2621.PDF
QuestysFileName
87-2621
QuestysRecordID
1632446
QuestysRecordType
12
Tags
EHD - Public
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APPLICATION FOR PERMIT u <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON 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 <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 /> Job Address � a b <br /> L t� D � L Y� City F' Lot Size S�X�T S PM <br /> Owner's Name A?U 1- C G�� Address �� � � ��/ 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 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 /> f'l Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout _. <br /> I I Irrigation __Approx. Depth I I Eastern Surface Seal Installed by _ <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done_ <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50') <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION l I DESTRUCTION rKJNo septic system permitted if public sewer is <br /> vailable 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 <br /> SEEPAGE PITS I 1 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 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: "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 ust c I for allequ' d inspections Complete drawing on reverse side. <br /> �[ Signed X Title: Oto Date: -7I —F7 <br /> r FOR DEPARTMENT USE ONLY <br /> Application Accepted by �1 ��Z Date ~ Area <br /> Pit or Grout Inspection by Date Final Inspection by Date 3p <br /> ,Hditional Comments: 'la <br /> Stk 466-6781 ❑ Lodi 369-362 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> Ap licant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT'NO. <br /> INFO CASH A /� <br /> + EH 13-24►REV.i/N 5) <br /> EH 14-26 i <br />
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