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87-1719
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4200/4300 - Liquid Waste/Water Well Permits
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87-1719
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Last modified
11/4/2019 10:50:57 PM
Creation date
12/1/2017 5:53:50 PM
Metadata
Fields
Template:
EHD - Public
ProgramCode
4200/4300 - Liquid Waste/Water Well Permits
RECORD_ID
87-1719
STREET_NUMBER
936
STREET_NAME
PLEASANT
STREET_TYPE
AVE
City
STOCKTON
SITE_LOCATION
936 PLEASANT AVE
RECEIVED_DATE
5/1/1987
P_LOCATION
AMERICO CORTOPASSI
Supplemental fields
FilePath
\MIGRATIONS\P\PLEASANT\936\87-1719.PDF
QuestysFileName
87-1719
QuestysRecordID
1900409
QuestysRecordType
12
Tags
EHD - Public
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E <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN 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 <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 G 161 City SJ�� Lot Size PM <br /> Owner's Name A C-12.1 ao ' 2 A9 Address LCA_VA A-;7— i4-e/5' Phone <br /> Contractor. dE4= t p f Address e!W * � <br /> cense No. 'y� Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYST PAIR ❑ �' OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LI DISPOSAL FLD. PROP. LINE " <br /> FOUNDATION AG LTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PRO M AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom Manteca Dia. of We11 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 _.-Ap x. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Typ f Pump H.P. State Work Done_ <br /> Well Destruction ❑ ell Diameter Sealing Material (top 501 <br /> Depth Filler Material lBelow 50'1. <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION (No septic system permitted if public sewer is <br /> available 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 R 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 ❑ Depth Size Number <br /> SUMPS ❑ 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 must call for all required inspection Complete drawing on reverse side. <br /> Signed/ Title: _4!::� <br /> Date: —Z—S <br /> y <br /> R DEPARTMENT USE ONLY <br /> Application Accepted by �7a .�Ih Date `^ _ Area <br /> Pit or Grout Inspection b 7— d� /4 g S=S` 7 <br /> pe Y Date al Inspection by Date _ <br /> Additional Comments: �+� �J Y� <br /> ❑ Stk 466-6761 ❑ 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 /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED SH RECEIVED BY DATE PERMIT'NO. <br /> a EH 13-24(REV.5 H 51 �'- <br /> EH 14-26 <br /> i <br />
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