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92-3038
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4200/4300 - Liquid Waste/Water Well Permits
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92-3038
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Last modified
4/1/2020 10:15:54 PM
Creation date
12/1/2017 8:40:47 PM
Metadata
Fields
Template:
EHD - Public
ProgramCode
4200/4300 - Liquid Waste/Water Well Permits
RECORD_ID
92-3038
STREET_NUMBER
18188
STREET_NAME
SEIDNER
STREET_TYPE
RD
City
ESCALON
SITE_LOCATION
18188 SEIDNER RD
RECEIVED_DATE
8/24/1992
P_LOCATION
VAN VLIET DAIRY
Supplemental fields
FilePath
\MIGRATIONS\S\SEIDNER\18188\92-3038.PDF
QuestysFileName
92-3038
QuestysRecordID
1919958
QuestysRecordType
12
Tags
EHD - Public
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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> I <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 /> ey- <br /> c� aJ. --A- <br /> Job nn <br /> Address - IRI City 1ka 10 Lot.Size PM <br /> Owner's Name __VS ell I a F lJ���Y Address Phone + <br /> , <br /> Contractor I <br /> r" <br /> r Xl _ f t ! �y�SSt1 P� <br /> Address License No. hone r j <br /> TYPE OF WELL/PUMP:; NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION El 1 <br />..� PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ i <br /> DISTANCE TO NEAREST: SEPTITANK 'SEWER,LINES DISPOSAL FLO. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED.USE 6TYPE OF WELL PROBLEM ARB� CONSTRUCTION SPECIFICA1-10N <br /> ❑ Industrial O Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Weil Casing <br /> ❑ Domestic/Private ID Gravel Pack El Tracy Type of Casing Specifications <br /> Cl Public (=] Other Cl Delta Deplih of Grout Seal Type of Grout _ <br /> 13 Irrigation --Approx. Depth l I Eastern Surface Seal installed by _ <br /> Repair Work Done ❑ Type of Pump H,P. State Work Done <br /> Well Destruction __171 Well Diameter Sealing Material {top 50'1 <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRIADDITIONV,�-DESTRUCTION l I (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Resideri-Ce-Z Commercial_ Other <br /> Number of living units:_�_ Number of bedrooms �. <br /> Character of soil to a depth of 3 feet: -� n Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well foundation Property Line - <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED 0 Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS I I Depth Size Number <br /> SUMPS %,_6"Distance to nearest: Well _ Foundation �1_4 t Property Line .3 5 <br /> DISPOSAL PONDS ❑ 2 <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 ::i <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 fallowing:"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 c II for all r wired inspections. Complete drawing on reverse side. <br /> Signed X Title: Date: <br /> FOR DEPARTMENT USE ONLY i <br /> Application Accepted by Date �L. Area <br /> Pit or Grout Inspection by Date Final Inspection by Date O, <br /> Additional Comments: 1K <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 935-6385 <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 K RECEIVED BY DATE PERMIT'NO. <br /> +.EH 1 2 <br /> 3-24 IREV.t i n sy R I g- � <br /> EH 14-28 !- ,S <br />
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