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90-2927
EnvironmentalHealth
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4200/4300 - Liquid Waste/Water Well Permits
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90-2927
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Last modified
2/29/2020 6:26:05 AM
Creation date
12/1/2017 10:37:11 AM
Metadata
Fields
Template:
EHD - Public
ProgramCode
4200/4300 - Liquid Waste/Water Well Permits
RECORD_ID
90-2927
STREET_NUMBER
17001
Direction
N
STREET_NAME
VETS
STREET_TYPE
RD
City
LODI
SITE_LOCATION
17001 N VETS RD
RECEIVED_DATE
10/30/1990
P_LOCATION
H J HARRIS
Supplemental fields
FilePath
\MIGRATIONS\V\VETS\17001\90-2927.PDF
QuestysFileName
90-2927
QuestysRecordID
1968661
QuestysRecordType
12
Tags
EHD - Public
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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL i 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 welUpump and the Rules and Regulations of the San Joaquin <br /> Local Health District. �I, <br /> Job Address 174 <br /> 0Q , � /LG( CitZLot Size/,atA� PM <br /> 60 6 <br /> Owner's Name/7.V. �� Id�. - _ Address R Phon <br /> 0 cmc 76 7 �z1yz 76 -y-s� <br /> Contract Address r 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 t' <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> I'] Public F1 Other ❑ Delta -Depth of Grout Seal Type of Grout <br /> I I Irrigation ` ___-Approx. Depth l I Eastern Surface Seal Installed by <br /> Repair Work,Done ❑ Type of Pump H.P. 14 State Work Done_ <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATIO REPAIR)ADDITION l 1 DESTRUCTION I ] INo septic system permitted if public sewer is 1 <br /> available within 200 feet.) <br /> Installation will serve: Residence Commercial Other <br /> Number of living units: / Number of ooms 3 <br /> Character of soil to a depth of 3 feet: ' Water table depth L/J <br /> SEPTIC TAMC ,�` Type/Mfg r <br /> Capacity No. Compartments <br /> PKG. 'TREATMENT PLT. ❑ I t Method of Disppsal (r <br /> Distance to nearest: We11 ...__.. Foundation Property Line <br /> LEACHING LINE r-K No. & Length of lines 4 Total length/size v K <br /> ! <br /> FILTER BED ❑ Distance to nearest: Well Foundation ✓ �C� Property Line <br /> r' f �!r s <br /> SEEPAGE PITS Depth s Size Number _ <br /> SUMPS,- :I. ❑ Distance to nearest: Well ADO Foundation. 10Property.Line <br /> DISPOSAL PONDS ❑ 1 — <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 s6 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." .__. , - i <br /> The applicant mcalif II quired inspections. Complete drawing on reverse siye Or r <br /> Signed X r Title: V. V Date: <br /> FOR DEPARTMENT USE ONLY <br /> i <br /> Application Accepted by q 'Date La ¢. Area <br /> it r Grout Inspection by Q to G� 6-245_e6^ Final Inspection by �7ate,r` <br /> Additional Comments: Z,� l 5 G�,r'c 4/ Q O� <br /> ❑ Stk 466-5781 r3 Lodi 369-3521 ❑ Manteca 823-7104 C1 T4cy 835-6385 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 20W, Stk., CA 95:201 <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH CK RECEIVED BY DATE PERMIT'NO. <br /> t EH 13-24 IREV.r i 8 57 O—D �} <br /> EH 14-26 1 rG�' {Q _TA2 <br />
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