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3500 - Local Oversight Program
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PR0544124
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Entry Properties
Last modified
2/8/2019 3:49:36 PM
Creation date
2/8/2019 3:20:09 PM
Metadata
Fields
Template:
EHD - Public
ProgramCode
3500 - Local Oversight Program
File Section
WORK PLANS
RECORD_ID
PR0544124
PE
3500
FACILITY_ID
FA0012144
FACILITY_NAME
ARCO STATION #6080
STREET_NUMBER
85
STREET_NAME
LOUISE
STREET_TYPE
AVE
City
LATHROP
Zip
95330
APN
19627010
CURRENT_STATUS
02
SITE_LOCATION
85 LOUISE AVE
P_LOCATION
07
P_DISTRICT
003
QC Status
Approved
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EHD - Public
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APPLICATION FOR PERMIT �..1 <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT ' <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone 1209) 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. h <br /> Job Address 0 y Cc Eta 6 V l.u,i t S e- �+t1 o, 9 53 City / Lot Size PM <br /> Owner's Name M rt k t 1 t4 4 Rt 1 Imo•^ Address _ r3 4 Na,,! f A?2 ,c r Phone -122-- <br /> /5-75 2?" <br /> ! .-,ais L1,4 t14 533 _ <br /> Contractor el �r 1.4 Address l7.fi ui A- Lr` y�11 / License No, s Phone 9 W9733 <br /> TYPE OF WELL/PUMP: NEW WELL J4 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 /> INTkNDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private D.Gravel Pack ❑ Tracy Type of Casing Ja,✓G Specifications <br /> ❑ Public '❑' Other El Delta Depth of Grout Seal Type of Grout <br /> El Irrigation /��Approx. Depth ❑ Eastern Surface Seat Installed by {� <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done �h <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> ( 41;0,4 Itis-Ps Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> available within 20t7 feet.) <br /> Installation will serve: Residence_ Commercial _ Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: _� 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 �7 <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well _ Foundation Property Line <br /> SEEPAGE PITS ❑ Depth Size Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ - <br /> I hereby certify that l 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." 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." <br /> The applicant must c I for all requiredi ctions. Complete drawing on reverse side. <br /> Signed -' Title: Date: <br /> �DR E ONLY <br /> Application Accepted by i Date ' / Area <br /> Pit or Grout Ins n �� �..z Date !V-Z4-9--?Final Inspection by Z4 J�.. _ Date�� � <br /> r <br /> Additional Com ts: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-M � <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1801 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY JH- OATE PERMIT NO. <br /> • EH 1429 PREY.z 951 �� . �aJ Gy�'` i�9/ !7 ��— <br />
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