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2900 - Site Mitigation Program
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PR0544154
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Last modified
2/15/2019 12:06:38 PM
Creation date
2/15/2019 11:52:25 AM
Metadata
Fields
Template:
EHD - Public
ProgramCode
2900 - Site Mitigation Program
File Section
FIELD DOCUMENTS
RECORD_ID
PR0544154
PE
2950
FACILITY_ID
FA0003095
FACILITY_NAME
JEFFERSON ESD-MONTICELLO ELEM
STREET_NUMBER
1001
STREET_NAME
CAMBRIDGE
STREET_TYPE
AVE
City
TRACY
Zip
95376
APN
24404010
CURRENT_STATUS
02
SITE_LOCATION
1001 CAMBRIDGE AVE
P_LOCATION
03
P_DISTRICT
005
QC Status
Approved
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EHD - Public
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APPLICATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work herein described. This <br /> application is made in compliance vith San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> Job Address /0,91 City V Lot Size/Acreage �— <br /> Owner's Name479�6 / -"01 �� d8ress �( A J L>✓IiL.G4J3cis..`/� Phone?,fP '3✓?O <br /> Contractor Address z ZS Tu _ License No.IL-S�z�a Phon <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT Cl DESTRUCTION XOut of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ <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 SPECIFICATION <br /> C) Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation M Dia. of Well Casing C <br /> C.) Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ �- Specifications -S yoC <br /> 11 Public C'1 Other fl Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation _Approx. Depth I I Eastern Surface Seal Installed by .,�i1uC-Z <br /> Repair Work Done U Type of Pump H.P. State Work Done _ <br /> Well Destruction ❑ Well Diameter Sealing Material i Depth <br /> Depth Filler Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted it public sewer is <br /> available within 200 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 <br /> LEACHING LINE Ll No. b Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> F <br /> SEEPAGE PITS Il Depth Size Number f <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> 1 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 County <br /> Home owner or licensed agent's signature cenifies the following: "1 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 cenify 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 applica st call f r all required kspections. Complete drawing on reverse side. <br /> / '! <br /> ✓ Signed X Title: ✓ PRESIDENT Date: ��T• `9 Z1 <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date Area <br /> Pit or Grout Inspection by Date Final Inspection by <br /> Additional Comments: <br /> Applicant - Return all copies o: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED CK 9 <br /> CA RECEIVY BY DATE PERMIT'NO. <br /> . EH 17.24 111EV.Iinpt �� <br /> EM ta•2e ` G <br />
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