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87-1659
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4200/4300 - Liquid Waste/Water Well Permits
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87-1659
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Entry Properties
Last modified
11/4/2019 10:50:18 PM
Creation date
12/1/2017 7:35:19 PM
Metadata
Fields
Template:
EHD - Public
ProgramCode
4200/4300 - Liquid Waste/Water Well Permits
RECORD_ID
87-1659
STREET_NUMBER
832
STREET_NAME
ROSEMARIE
STREET_TYPE
LN
City
STOCKTON
SITE_LOCATION
832 ROSEMARIE LN
RECEIVED_DATE
04/29/1987
P_LOCATION
JBL FINANCIAL
Supplemental fields
FilePath
\MIGRATIONS\R\ROSEMARIE\832\87-1659.PDF
QuestysFileName
87-1659
QuestysRecordID
1913243
QuestysRecordType
12
Tags
EHD - Public
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oJi31�7 ce)j . <br /> . „� APPLICATION FOR PERMIT <br /> SAN JOAQUIN'LOCAL HEALTH DISTRICT <br /> 1601 E:1 HAZEL i OWAVE., 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 Addressa�l/e`�/ � - City' Jam/l�/`� Lot Size PM <br /> Owner's Name _.ti�LL• L�.— r�.��J2�'ll;alAddress P,0. 6K 7 ` �� �67J Phone 4 <br /> `r�L(t�Phone' <br /> Contractor �� /�� Address License No. Phone' <br /> TYPE OF WELL/PUMP: NEW WELL ❑ ,�.�c WELL RE"LACEMENT-E]-, DESTRUCTION <br /> PUMP INSTALLATION ❑ -SYSTEM REPAIR ❑ f� OTHER ❑ <br /> _DISTANGE__TQ-NEARESZ ---- _SEWER LINES .__DISP_OSAL_ELD. -- _PROP.._LINE_ <br /> FOUNDATION AGRICULTURE WELL I OTHER WELL PITS/SUMPS 1" <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 d Specifications <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.F,. a ► r State Work Done . <br /> Well Destruction Well Diameterrj + Sealing Maiterial {top 501 <br /> T Depth;t +/ oaf? Filler Material {Below 501 <br /> TYPE OF SEPTIC WORK, NEW INSTALLATION C1REPAIR/ADDITION ❑ DESTRUCTION El (No system(No se <br /> p y permitted if public sewer is � <br /> e i� available within 200 feet.) ^� <br /> Installation will serve: Residence�ComFnePcial-Other <br /> Number of living unts: Number bf bedrooms <br /> Character of soil tofa-doth-of 3-feet: } Water table depth ; <br /> SEPTIC TANK . ❑ (Type/Mfg Capacity I No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> # Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE E No. & LLngth of lines Total length/size <br /> FILTER BED ❑ Mistance to nearest: Well i Foundation Property Line <br /> SEEPAGE PITS ❑ #Depth '•s-""'- Size g - } Number <br /> SUMPS ❑ =Distanceto_ne�est: 5Well f i Foundation "Property Line <br /> DISPOSAL PONDS[[[ ❑ e .r t may" <br /> I hereby certify that I have prepared this application and that}the work will be`dane 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."l 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 i6"become subject to workman's compensation law's of California." Contractor's hiring or sub-contracting signature <br /> certifies the following: "Fcertify 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." r r.I i € F <br /> The applicant r all re pections. Complete drat ing on reevveerse de. <br /> Signed X� � tlDate: <br /> ' t DEPARTMENT USE ONLY <br /> Application Accepted by rr 4 Date '� Areaef <br /> f 1 r <br /> Pit or Grout Inspection by �J-�p - Date �7 Final Inspe-tion by ' Date `� <br /> Additional Comments: <br /> ---.---:�❑-Stk- 466-6781 3621---- B_ManteCa__.�_623-71 ❑ Tracy�8354M--M, �. <br /> -, -.:.Applicant--.Return all-copies-to:--Environmental Health Permit/Services 1601-E. Hazelton!Ave ,.P-:O..Box-2009,-Stk.,!CA 95201 . w - <br /> INFO AMOUNT DUE AMOUNFEET REMITTED* CASH RCK ECEIVED BY DATE PERMIT NO, <br /> + EH 1324(REV.t/851 — 5 <br />
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