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87-1689
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4200/4300 - Liquid Waste/Water Well Permits
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87-1689
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Last modified
11/4/2019 10:50:43 PM
Creation date
12/1/2017 11:23:26 PM
Metadata
Fields
Template:
EHD - Public
ProgramCode
4200/4300 - Liquid Waste/Water Well Permits
RECORD_ID
87-1689
STREET_NUMBER
1728
STREET_NAME
SUNNYSIDE
City
STOCKTON
SITE_LOCATION
1728 SUNNYSIDE
RECEIVED_DATE
04/30/1987
P_LOCATION
MARTIN AGUIRRE
Supplemental fields
FilePath
\MIGRATIONS\S\SUNNYSIDE\1728\87-1689.PDF
QuestysFileName
87-1689
QuestysRecordID
1939593
QuestysRecordType
12
Tags
EHD - Public
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APPLICATION^FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE.,.STOCKTON, CA ��►V <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. rT ,i Y <br /> Job Address ,�7.x� Ll`1�� / il,C_ Citi2wl of Size PM <br /> Owner's Name ,,Ur3�6�f GL!/ r'fY Address n <br /> Phoe <br /> Contractor ! Address License No. Phone <br /> f�� <br /> TYPE OF WELL/PUMP: �� NEW WELL D WELL REPLACEMENT El DESTRUCTION LJ <br /> PUMP INSTALLATi Ll SYSTEM REP R Ll OTHER ❑ <br /> DISTANCE TO NEAREST: SEF�TIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WE OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PR BLEM AREA STRUCTION SPECIFICATIONS <br /> ElIndustrial Ll Open Bottom 1-1nteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ICITra Type of Casing Specifications <br /> ❑ Public ❑ Other ❑ Delia Depth of Grout Seal Type of Grout <br /> ❑ Irrigation �M Approx. Depth r ❑ Eastern Surface Seal Installed by .. <br /> Repair Work Done ❑ Typ h of Pump H.P. State Work Done <br /> Well Destruction ❑ Well DiameterSealing terial {top 50'I <br /> Depth Filler Materiai'(Below 501 I <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION lNo-septic system permitted if public sewer is <br /> i - 1,available within 200 feet.) <br /> Installation will serve: Residence Commercial Other <br /> Number of living units: Number of bedrooms k <br /> Character of soil to a depth of 3 feet: Water table depth <br /> .l <br /> SEPTIC TANK ❑ Type/Mfg a Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ qIl Method of Disposal <br /> EG Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines , Total length/size <br /> M <br /> FILTER BED ❑ Distance to nearest: Well °Foundation Property Line <br /> SEEPAGE PITS ❑ Depth 'y Size Number I <br /> SUMPS ❑ Distance to nearest:, Well Foundation -i 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. 1'-? <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 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 /> tion laws of California."., << I r <br /> The applicant must call for all required inspections. Complete drawing on reverse side. <br /> f kSigned Title: Date: <br /> EPA T-USE ONLY <br /> Application Accepted by �p _, ?Y*� Date -3ta07__ Area <br /> Pit or Grout Inspection by E Date Final Inspection by ladf=7< Date <br /> Additional Comments: ' e <br /> ❑ Stk 466-6781 ❑ Lodilli 369-3621 ❑ Manteca 823-7104 ❑ Tracy 83x63$5 <br /> Applicant - Return all copies to: <br /> Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O.:Box 2009, Stk., CA 95201 <br /> j FEE AMOUNT DUE! AMOUNT REMITTED CK RECEIVED BY DATE PERMn"NO. <br /> INFO CASH <br /> + EH 13-24IgEV.tiH5r �f �Q �Ir.GGr <br /> EH 14-28 �i� � � �`- l "-Lcm � <br /> F <br /> ;6 it <br />
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