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87-1841
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4200/4300 - Liquid Waste/Water Well Permits
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87-1841
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Last modified
11/6/2019 10:07:01 PM
Creation date
12/2/2017 12:43:35 AM
Metadata
Fields
Template:
EHD - Public
ProgramCode
4200/4300 - Liquid Waste/Water Well Permits
RECORD_ID
87-1841
STREET_NUMBER
352
Direction
S
STREET_NAME
THELMA
STREET_TYPE
AVE
City
STOCKTON
SITE_LOCATION
352 S THELMA AVE
RECEIVED_DATE
5/8/1987
P_LOCATION
ROD & DEBBIE ALLENBOUGH
Supplemental fields
FilePath
\MIGRATIONS\T\THELMA\352\87-1841.PDF
QuestysFileName
87-1841
QuestysRecordID
1944385
QuestysRecordType
12
Tags
EHD - Public
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APPLICATION FOR PERMIT ,S <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA N © sL�Dt't�4� <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) h_- <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. Thi 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 /> Job Address �r !t.0 I�l�(� �/�Y�lt_ City Lot Size PM <br /> Owner's Name b-Cli �1'e 1 TUB' �Adi 156 >�1�t � Phone <br /> Contractor f of Address License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION D SYSTEM REPAIR ❑ OTHER 0 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial I ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack D Tracy Type of Casing Specifications <br /> 1-1 Public n Other Ll Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation _..Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump f H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTIO o septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence Commercial— Other` <br /> Number of living units: Number of bedrooms 4 b <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK D Type/MfgLN 4, —4 Capacity � No. Compartments <br /> PKG. TREATMENT PLT. ❑ it <br /> * Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines ' Total length/size <br /> FILTER BED D Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS I i Depth Size 0. Number <br /> SUMPS D Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS Ll <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."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,1 shall employ persons subject to workman's compensa- <br /> tion laws of C i rnia." <br /> The applica mu t c for all r uir i ction . Comp) drawing on reverse side. <br /> Signed X Title: Date: Slit 4�7 <br /> FO ENT USE ONLY <br /> Application Accepted by ,� _ _ Date �� rea <br /> Pit or Grout Inspection by Da�tte Final Insppeectia by Date <br /> e7v%-e2 f �t a cc t lr?d <br /> Additional Comments: P4C, <br /> G r7Q <br /> D Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 "JG ct CIp � <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 CK RECEIVED BY DATE�1_ PERMITNO. <br /> ♦ EH 14-24 1REV.1/x 55 �U J 3S7 <br />
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