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85-180
EnvironmentalHealth
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EHD Program Facility Records by Street Name
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TSIRELAS
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16072
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4200/4300 - Liquid Waste/Water Well Permits
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85-180
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Entry Properties
Last modified
8/23/2019 10:08:17 PM
Creation date
12/2/2017 1:56:59 AM
Metadata
Fields
Template:
EHD - Public
ProgramCode
4200/4300 - Liquid Waste/Water Well Permits
RECORD_ID
85-180
STREET_NUMBER
16072
STREET_NAME
TSIRELAS
City
TRACY
SITE_LOCATION
16072 TSIRELAS
RECEIVED_DATE
02/28/1985
P_LOCATION
WDO INC
Supplemental fields
FilePath
\MIGRATIONS\T\TSIRELAS\16072\85-180.PDF
QuestysFileName
85-180
QuestysRecordID
1952520
QuestysRecordType
12
标签
EHD - Public
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S <br /> APPLICATION FOR^PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT �. <br /> 1601 E. HAZELTON AVE:; STOCKTON, CA ` ' <br /> Telephone 12091 466-67$1 <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. � <br /> Job Address City Lot Size Z ,�,.��� PM <br /> Owner's Name d Address 2 O r <br /> - Phone <br /> t <br /> Contractor's Name 1� 7 . License No. �� Phone <br /> TYPE OF WELL/PUMP: r NEW-WELL 0. WELL REPLACEMENT O 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 /> INTENDED USE TYPE OF WELL PROBLEM AREA" CONSTRUCTION SPECIFICATIONS ' <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> ❑ Public ❑ Other El Delta _ Depth of Grout Seal Type of Grout <br /> [I Irrigation <br /> --Approx. Depth :❑ Eastern Surface Seal Installed by <br /> Work Done ❑ <br /> Repair Type H.P. <br /> p YP of Pump $T' State Work Done a <br /> Well Destruction ❑ Well Diameter y Sealing Material (top 501 0 ,) <br /> Depth Filler Material {Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is 4 <br /> available within_200,feet.) .�;;.,r <br /> Installation will serve: Residence L Commercial Other' <br /> Number of living units:__/_ Number of bedrooms <br /> Character of soil to a depth of 3 feet: r7QkT,–. Water table depth <br /> SEPTIC TANK `+ ❑ Type/Mfg L� -. ��i E Capacity &CeanV_ No. Compartments <br /> PKG. TREATMENT PLT. ❑ _ Method of Disposal �w <br /> Distance to nearest: Well`',_ Foundation Property Line <br /> LEACHING LINE No. & Length of lines _- 'j�` t`� - ' ' Total-length/size Ub~117�7— <br /> �+ <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS ❑ Depth <br /> Size "`IV mlier'�` <br /> SUMPS ❑ Distance to nearest: Well; Foundation Property Line <br /> DISPOSAL PONDS ❑ %0 7t <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. i <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: "!certify that in the performance of the work for which this permit is issued,I shall empioy persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant must call for all r ulre inspections. Complete drawing on 'reverse side. <br /> Signed X �,,- Title: l Date: 'Z` / < <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by DateArea <br /> 07 t <br /> Pit or Grout Inspection by Date Final Inspection by //// Date <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 0 Tracy 835-6385 <br /> Applicant Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> t <br /> + (FEE AA/MOUNT DUE /A�MO�UNT�REMITTED CASK RECEIVED BY DATE PERMIT"NO. <br /> + EH 14-281REV.10183) /�1 � /' _ Os AleO f� <br />
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