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89-206
EnvironmentalHealth
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VAN ALLEN
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4200/4300 - Liquid Waste/Water Well Permits
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89-206
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Entry Properties
Last modified
12/26/2019 10:08:43 PM
Creation date
12/1/2017 10:18:57 AM
Metadata
Fields
Template:
EHD - Public
ProgramCode
4200/4300 - Liquid Waste/Water Well Permits
RECORD_ID
89-206
STREET_NUMBER
15305
Direction
S
STREET_NAME
VAN ALLEN
STREET_TYPE
RD
City
TRACY
SITE_LOCATION
15305 S VAN ALLEN RD
RECEIVED_DATE
1/31/89
P_LOCATION
JOHN VANDERSCHANE
Supplemental fields
FilePath
\MIGRATIONS\V\VAN ALLEN\15305\89-206.PDF
QuestysFileName
89-206
QuestysRecordID
1967380
QuestysRecordType
12
Tags
EHD - Public
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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE.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 <br /> i City Lot Size �° PM <br /> Owners Name �J6+ /1 �� �s <br /> Phone <br /> Contactor v6�Q W761 <br /> Address License No. 3 Phone 6� <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 /> ("1 Public L-] Other Cl Delta Depth of Grout Seal Type of Grout <br /> ! I Ir ligation —.Approx. Depth 1J Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done_ <br /> L <br /> Well Destruction .❑—".Well Diameters Sealing Material (top 501 -- --w•e <br /> ' Depth Filler Material (Below 501 T ' <br /> F <br /> STYPE OF SEPTIC WORK: NEW INSTALLATION 'IREPAIR/ADDITION i I DESTRUCTION I I,(No septic system permitted if public sewer is <br /> 0 1 '� available within 200 feet.) <br /> �x ..om <br /> Installation wiq'serve: yResidence_ Commercial Othe'r�b <br /> #Number of living units., —L'— Number of ballrooms_ �? n S <br /> Character of soil to a depth of 3 feet: Water table depth U 1 <br /> SEPTIC TANK FI Type/Mfg Capacity <br /> �e< Ca Z <br /> p Y� ._ _ No. Compartments <br /> -PKG'TREATMENT PLT. ❑ r �, _ Method of Disposal <br /> Distance to nearest: Well Foundation � Property Line f n <br /> LEACHING LINE ❑ No. & Length of lines CSS <br /> rfT <br /> r otallength/size <br /> FILTER BED ❑ Distance to nearest: Well. [%D Foundation t` Property Line ` n <br /> SEEPAGE PITS I'] Depth Size +eNuuTber. <br /> SUMPS L1 Distance to nearest: Well. Foundation=5--'o't� 1 Property Line (( <br /> DISPOSAL PONDS ❑ tk ,ri (� <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. _ X t__ <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."Contractors hiring or sub-contracting signature <br /> certifies the following: "I certify that in the performance of the work for which this permit is issued, l shall employ persons subject to workman's compensa- <br /> tion laws of California." 1� # S# <br /> 11 <br /> Tha applicant must call for all a required inspections..}pections..Completa drawing on reverse side. , <br /> Signed X Title: /I i ii Date: <br /> DEPARTMENT USE ONLY <br /> Application Accepted by T Date Area <br /> 9 <br /> Pit or Grout Inspection by Date Final Inspection b� Date <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 0 Tracy 835-6385 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95.201 <br /> FEE ?'AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMITNO. <br /> INFO <br /> a.EH 13-24 <br /> EH 14-28 HEV,1/n 51 O r P"1• vV �/ ! /"�,._ ��_dS`-'i[J <br /> n <br /> i f <br />
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