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83-538
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ROBINDALE
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4200/4300 - Liquid Waste/Water Well Permits
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83-538
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Last modified
8/7/2019 6:12:37 AM
Creation date
12/1/2017 7:27:16 PM
Metadata
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Template:
EHD - Public
ProgramCode
4200/4300 - Liquid Waste/Water Well Permits
RECORD_ID
83-538
STREET_NUMBER
2760
STREET_NAME
ROBINDALE
City
STOCKTON
SITE_LOCATION
2760 ROBINDALE
RECEIVED_DATE
06/15/1983
P_LOCATION
VAN DEPOL
Supplemental fields
FilePath
\MIGRATIONS\R\ROBINDALE\2760\83-538.PDF
QuestysFileName
83-538
QuestysRecordID
1911156
QuestysRecordType
12
Tags
EHD - Public
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4. APPLICATION FOR PERMIT <br /> 4' SAN JOAQUiN LOCAL HEALTH DISTRICT (� <br /> 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. <br /> Telephone (209) 466-6781 (� <br /> DATE ISSUED w'—�S '•/� <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 <br /> described. This application is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for wel3/pump <br /> and the Rules anA Re ulati�o}ns othe Sar. oaqui5,Local Health District. <br /> Job Address V Subdivision Name <br /> f Owner's Name Address Phone <br /> Contractor's Na a No. 117 6 Phone0 73 140 4A Ce <br /> TYPE OF WELL/PUMP WORK: NEW WELL Q WELL REPLACEMENT DESTRUCTION U <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 /> k INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> J Industrial U Open Bottom Manteca Dia, of Well Excavation <br /> U Domestic/Private F1 Gravel Pack Tracy Dia. of Well Casing <br /> �] Public Fj Other ❑ Delta <br /> Type of Casing <br /> F-1 Irrigation Approx. Eastern Specifications <br /> [ Cathodic Protection Depth <br /> Depth of Grout Seal <br /> Geophysical <br /> Type of Grout <br /> U Other y <br /> Surface Seal Installed by (— <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction F_ Well Diameter Sealing Material {top 50') <br /> Depth Filler Materi B e,16wl D') Q <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION U REPAIR/ADDITION (No septic tank or seepage pit permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence Commercial _ Other <br /> Number of living units: Numbe?of bedrooms __._ . Lot size ;Z G� ✓ / <br /> Character of soil to a depth of 3 feet: a water table depth _70 <br /> SEPTIC TANK Type/Mfg - __ Capacity 1 No. Compartments �* <br /> PKG. TREATMENT PLT. Type/Mfg Capacity Method of Disposal <br /> SEWAGE SYSTEM Distance to nearest: Well Foundation, A--% Line <br /> DESTRUCTION <br /> LEACHING LINE U No. & Length of lines, Total length/size <br /> FILTER BED Distance to nearest: 4Well Foundation Property Line <br /> SEEPAGE PITS ❑ Depth <br /> 5ize) Number <br /> SUMPS U Distance to nearest: i,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 <br /> ordinances, state laws, and 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 <br /> permit is issued, I shall not employ any person in such manner as to become subject to workman§ compensation laws of California." / <br /> Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work for which <br /> this permit is issued, 1 shall employ persons subject to workman's compensation laws of California." <br /> The applica mu all for 1 equired inspec ns. Complete drawing on reverse side. <br /> Signed X Title: L(%Ll1L_ Date: <br /> f <br /> 7M EN 5E ONLY <br /> Application Accepted Area Stk 466=678 <br /> Additional Comments: Lodi 3 621 <br /> Pit or Grout Inspection by Date Manteca 823-7104 <br /> Final Inspection by J_ Date ❑ Tracy 835-6385 <br /> Applicant - Return all copies to: . Environmental Health Permit/Services 1601 E. Hazelton Ave., P.D. Box 2009, Stk., CA 95201 <br /> FEE BASE AMOUNT DUE AMOUNT REMITTED f77RECEIVED BY DATE PERMIT NO. <br /> INFO <br /> � � [. NYS <br /> EH 13-24 REV. 10/82 10/82 500 <br /> 14-26 <br />
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