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86-926
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STONEY CREEK
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4200/4300 - Liquid Waste/Water Well Permits
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86-926
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Last modified
9/9/2019 10:23:01 PM
Creation date
4/6/2018 4:29:34 PM
Metadata
Fields
Template:
EHD - Public
ProgramCode
4200/4300 - Liquid Waste/Water Well Permits
RECORD_ID
86-926
STREET_NUMBER
2864
Direction
E
STREET_NAME
STONEY CREEK
STREET_TYPE
CIR
City
ACAMPO
APN
00529028
SITE_LOCATION
2864 E STONEY CREEK CIR
RECEIVED_DATE
8/1/1986
P_LOCATION
HENRY CLAUSEN
Supplemental fields
FilePath
\MIGRATIONS\S\STONEY CREEK\2864\86-926.PDF
QuestysFileName
86-926
QuestysRecordID
1937533
QuestysRecordType
12
Tags
EHD - Public
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J <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> RMIT EXPIRES 1 YEAR FROM DATE ISSUED ,. <br /> Y� ('� Corpplete � Triplicate) <br /> �.K- y-cl application is <br /> Application is hereby made to the San Joaquin Local Balt District for a rmit to construct andlor install the work herein described.This <br /> made in compliance with San J quin County Ordinance No.549 for sewage or No.18G1 for,well/ and the Rukes and Regulationof it San Joaquin <br /> � <br /> Local Health District. /f/ � /Vr"vn•'�h\ ( <br /> _ of Size ' <br /> Ci <br /> Job Address <br /> 6' <br /> f Address ne <br /> Owner's Name r� <br /> Phone <br /> RUCTION <br /> oG <br /> Contractor's Nam <br /> p icense No. <br /> TYPE OF WE NEW,WELL �' WELL REPLACEMENT ❑ DESTRUCT ION ❑ s <br /> SYSTEM REPAIR ❑ ,+ y - OTHER L7. _ <br /> PUMP INSTALLATION [ , DISPOSAL FLD. 'PROP. LINE <br /> DISTANCE TO NEAREST: 5EP+1C TAN' K SEWER LINES AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> FOUNDATION .�� <br /> INTENDED USE TYPE OF,WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS'` Dia. of Well Casing 5 <br /> 11 Industrial pen ottom ❑ Manteca Dia. of Well Excavati of Casing L EARPne Specifications . 6 <br /> El❑ Gravel Pack Tracy Type <br /> / Depth of Grout Seal L Type ut <br /> ❑ Public ❑ Other - El Delta ✓_ <br /> ❑ Irrigation +PPrax. Depth ❑ E ern Surface Seal Installed by <br /> P State Work Done <br /> Repair Work Done El Type IOf Pd�mp <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50'l <br /> Depth i' Filler Material {Below S0'} <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ElpESTRUGTION ❑ available ble�with within200feet.) if public sewer is <br /> Installation will serve: Residence— Commercial— Other <br /> Number of living units: ! Number of bedrooms Water table depth a <br /> Character of soil to a depth of 3 f et: <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments � <br /> Method of Disposal <br /> PKG. TREATMENT PLT. ❑ Property Line <br /> Distance to nearest: Well Foundation <br /> 4 <br /> Tota! length/size <br /> LEACHING LINE ❑ No.'&length of es Property7Uiine— <br /> FILTER <br /> BED ❑ Distance to n$arbst: WellFoundationSize Number <br /> SEEPAGE PITS ❑ Depths Property <br /> SUMPS ❑ pistance to nearest: Well Foundation <br /> DISPOSAL PONDS ❑ -� ! <br /> 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 `1 <br /> rules and regulations of the San Joaquin Local Health District. ] <br /> following: "I certify that in the performance of the work for which this permit is issued, I shallnot <br /> Home owner or licensed agent's signature certifies the 1 <br /> employ any person in such manner s of California.” Contractor's hiring or sub contracting signature <br /> as to become subject to workman's compensation law <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 i <br /> tion laws of California.1. <br /> The applicant mu call f r all requirQd inspections. Comple d wing on reverse side. / <br /> Title: 01 <br /> Date: [� <br /> Signed <br /> ' R DEPARTMENT USE ONLY <br /> i Date Area O <br /> Application Accepted by <br /> Date +nal inspection by Date <br /> Pit or Grout Inspection by <br /> tJill <br /> Additional Comments: <br /> ❑ Stk 466-6781 Lodi 369-3621 ElManteca 823-7104 ElTracy 836-6385 <br /> Applicant- Return all opi to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEEK RECEIVED BY DATE PERMIT�'NO. <br /> INFO <br /> AMOUNT DUE AMOUNT(�REMITTED <br /> +EH 73-24 IREv.10!83) � � C�`� t"�� • � � �'��� � 9 a <br /> EH 14-28 f: <br />
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