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85-696
EnvironmentalHealth
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ROBINSON
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4200/4300 - Liquid Waste/Water Well Permits
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85-696
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Entry Properties
Last modified
8/25/2019 10:12:46 PM
Creation date
12/1/2017 7:27:40 PM
Metadata
Fields
Template:
EHD - Public
ProgramCode
4200/4300 - Liquid Waste/Water Well Permits
RECORD_ID
85-696
STREET_NUMBER
13182
Direction
S
STREET_NAME
ROBINSON
City
ESCALON
SITE_LOCATION
13182 S ROBINSON
RECEIVED_DATE
06/27/1985
P_LOCATION
FRANK FARIA
Supplemental fields
FilePath
\MIGRATIONS\R\ROBINSON\13182\85-696.PDF
QuestysFileName
85-696
QuestysRecordID
1911407
QuestysRecordType
12
Tags
EHD - Public
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N <br /> d <br /> c <br /> APPLICATION,FOR PERMIT <br /> I SAN JOAQUIN LOCALHEALTHDISTRICT <br /> 1601 E. HAZE TON AVE., STOCKTON, CA <br /> I' Telephone (209) 466-6781 t , <br /> U PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) . w. <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. ,- y ,;- .. v'� 14 <br /> Job Address 1 c —! l"L S _ city ^^' Lot Size PM <br /> _ h <br /> Owner's Name i� i Address _ Phone <br /> Contractor's Name License No. L _ Phone I <br /> TYPE OF WELL/PUMP: NEW WELL ❑ : WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> E PUMP INSTALLATION SYSTEM REP R 113 OTHER El <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES __ DISPOSAL FLD: PROP. LINE [` " <br /> FOUNDATION i AGRICULTURE WELL tSTHER-WELL PITS/SUMPS \ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom y LJ Manteca Dia, of Well Excavation Dia. of Well Casing <br /> 14 Domestic/Private [_1-Gravel Pack ❑ Tracy Type of Casing Specifications <br /> ❑ Public ❑ Other . ❑ Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation ----�4pprox. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type,Vf Pump .1G,, H.P. � State Work Done <br /> Well Destruction ❑ Well biometer -Sealing Material {top 501 <br /> Depth 1 Filler Material IBelow 50') <br /> I TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ 'REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> l available within 200 feet.) <br /> t <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. EJi Method of Disposal <br /> E istance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines 1 !' Tatarl•length/size <br /> FILTER BED ❑ pistance to nearest: Well Foundation Property Line <br /> j Y <br /> } SEEPAGE PITS L1Depth Siza_ Number <br /> i SUMPS ❑ bistance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> hereby certify that I have prepared this application and thai 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 /> C 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 /> i 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 /> k — tion_laws of California."— <br /> The <br /> alifornia.'The applicant ust cell or all r uired inspeictions. Complete drawing on re rse side. <br /> -- -- — - — r _ C <br /> Title: <br /> Signed t <br /> i FOR DEPARTMENT USE ONLY <br /> T r1 <br /> Application Accepted by Date Area <br /> Pit or Grout Inspection by Date Final Inspection b Datetr <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 83 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 09 <br /> E. Hazelton Ave., P.O. Box 20 , Stk., CA 95201 <br /> i II <br /> FEEAMOUNT DUE AMOUNT REMITTED CK 8 GASH RECEIVED BY DATE PERMIT"NO. <br /> INFO G <br /> G +E14 13-24 EH 13-28(REV.101831 s ��7 9S A. <br />
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