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89-744
EnvironmentalHealth
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4200/4300 - Liquid Waste/Water Well Permits
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89-744
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Last modified
1/9/2020 10:08:06 PM
Creation date
12/1/2017 10:04:50 PM
Metadata
Fields
Template:
EHD - Public
ProgramCode
4200/4300 - Liquid Waste/Water Well Permits
RECORD_ID
89-744
STREET_NUMBER
5265
Direction
E
STREET_NAME
SONORA
STREET_TYPE
ST
City
STOCKTON
SITE_LOCATION
5265 E SONORA AVE
RECEIVED_DATE
04/10/1989
P_LOCATION
ESPIRIDION RODRIGUEZ
Supplemental fields
FilePath
\MIGRATIONS\S\SONORA\5265\89-744.PDF
QuestysFileName
89-744
QuestysRecordID
1930220
QuestysRecordType
12
Tags
EHD - Public
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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. NAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 t ` <br /> PERMIT EXPIRES 'I 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 Cou'my 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 Address 5A6S IEi eAOr.4 T _ City ::570_C ;!i17ti Lot Size +; f04 PM <br /> Owner's Name_ Address '7 5mw r 1' f Phone ; �O 6 S z- <br /> Contractor ;�i, Address 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 0 Open Bottom ❑ Manteca pia- of Well Excavation Dia. of Well Casing <br /> Ll Domestic/Private V Gravel Pack ❑ Tracy Type of Casing Specifications <br /> M Public Ci Other 1 ❑ Delta Depth of Grout Seal Type of Grout <br /> I I hricJation Approx. Depth l J Eastern Surface Seal Installed by O <br /> Repair Work Done 12 *Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameters Sealing Material (tap 50'l " <br /> Depth Filler Material (Below 50') _ <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I i REPAIR/ADDITION I 1 DESTRUCTION (No septic system permitted if public sewer is <br /> `---�'yINavailable within 200 feet) <br /> Installation will serve: Residence 1 Commercial— Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: I Water table depth <br /> SEPTIC TANK ❑ Type/Mfg I Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ I Method of Disposal <br /> Distance to nearest: Well Foundation Property Line i} <br /> LEACHING LINE ❑ No. & Length of lines z- t Total length/size <br /> FILTER BED ❑ Distance to nearest: Well i Foundation Property Line <br /> SEEPAGE PITS 1 1 Depth Size 1 Number <br /> SUMPS ❑ Distance to nearest: Well 4Foundation. - 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 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 to become subject to workman's compensation laws of California."Contractors hiring of sub-contracting signature <br /> certifies the following: "I certify that in th#performance of the work for which this permit is issued, I shall employ persons subject to workman's compansa- <br /> tion laws of California <br /> The applicants call ora required inspections. Complete drawing on reverse side. <br /> r t <br /> Signed X + c Title: Date: tJo� 0 l <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by ` Qi Date �rea <br /> Pit or Grout Inspection by Date Final Inspection by ate <br /> Additional Comments: <br /> Cl Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 i <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201FEE ' <br /> INFO AMOUNT DUE i AMOUNT REMITTED CK 9,y.CASH RECEIVED BY J DATE PERMIT'•N'O. <br /> + EH 13-24 IREV.1/Kb) �5, 1 i 1� <br /> EH 14-26 ( I V <br />
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