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87-4268
EnvironmentalHealth
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4200/4300 - Liquid Waste/Water Well Permits
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87-4268
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Last modified
11/23/2019 10:07:07 PM
Creation date
12/2/2017 12:29:32 AM
Metadata
Fields
Template:
EHD - Public
ProgramCode
4200/4300 - Liquid Waste/Water Well Permits
RECORD_ID
87-4268
STREET_NUMBER
16350
STREET_NAME
TARGOWSKI
City
TRACY
SITE_LOCATION
16350 TARGOWSKI
RECEIVED_DATE
12/07/1987
P_LOCATION
DAVE OLMSTEAD
Supplemental fields
FilePath
\MIGRATIONS\T\TARGOWSKI\16350\87-4268.PDF
QuestysFileName
87-4268
QuestysRecordID
1942969
QuestysRecordType
12
Tags
EHD - Public
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i <br /> - - j <br /> APPLICATION'FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> k <br /> 1641 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> I <br /> PERMIT EXPIRES 11-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 /> Joh Address N <br /> 4 1 '+' rS Lot Size PM T <br /> ( city <br /> Owner's Namey/a �)w►S end Address Phone <br /> t _ - - � <br /> -._....— �[� t � Phone �� ! <br /> Contractor �•- r r� Address w � �{,�71��� License No. � <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ f SYSTEM REPAIR ❑ OTHER ❑ �t <br /> DISTANCE TO NEAREST: SEPTIC TANK t ..SEINER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS ' <br /> INTENDED_ USE TYPE OF WELL PROBLEM,AR EA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia- of Well Excavation Dia. of Well Casing a <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> f'i Public ❑ Other Ll Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation Approx. Depth I ) Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P., State Work Done <br /> Well Destruction ❑ Well;Diameter Sealing Material Itop 50'1 V <br /> Depth Filler Material iBelow 50') n <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION LI DESTRUCTION I I (No septic system permitted if public sewer is CT <br /> available within 200 feet.) <br /> " Installation will serve: Residence Commercial_ Other _ <br /> Number of living units: Number of Dedrooms 13 "- 1 <br /> Character of soil to a depth of 3 feet: E�f54'')I°� t __ Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments (1 <br /> PKG. TREATMENT PLT. ❑ Method of Disposal C` <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE No. & Length of lines ! kQTotal length/size <br /> FILTER BED ❑ Distance to nearest: Weir�bfJ-1'' Foundation Property Line <br /> s r <br /> SEEPAGE PITS l I Depth "'rte Size ' Number <br /> SUMPS Ll Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ a <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. t � : ' ' <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,!/shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant must cal- for all required inspections: Complete drawing on reverse side. <br /> Signed X Title: t -,_oKILil <br /> Date: <br /> 'FOR ARTMENT'USE ONLY <br /> l.0 ", p <br /> Application Accepted by \Date Area <br /> Pit or Grout Inspection,by Date Final Inspection,.-by Date! ' <br /> Additional Comments: •�` ,t <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621,1 ❑ Manteca 823-7104 .❑ Tracy 8356385 <br /> Applicant--.Return all copies.to: Environmental Health Permit/Services 1601 E. Hazelton Ave.,;P.O. Box 2009;Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. <br /> INFO CASH <br /> + EH 1324(REV.t i H 5) <br /> EH 14-29 <br />
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