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2900 - Site Mitigation Program
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PR0009063
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Last modified
5/2/2019 1:27:56 PM
Creation date
5/2/2019 1:21:56 PM
Metadata
Fields
Template:
EHD - Public
ProgramCode
2900 - Site Mitigation Program
File Section
FIELD DOCUMENTS
RECORD_ID
PR0009063
PE
2960
FACILITY_ID
FA0003785
FACILITY_NAME
PACIFIC TRIPLE E LTD
STREET_NUMBER
8690
Direction
W
STREET_NAME
LINNE
STREET_TYPE
RD
City
TRACY
Zip
95304
APN
253-210-180-00
CURRENT_STATUS
01
SITE_LOCATION
8690 W LINNE RD
P_LOCATION
99
P_DISTRICT
005
QC Status
Approved
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EHD - Public
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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PIIBLIC ELEALTH SERVICES � <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P O BOX 2009 , STOCKTON, CA 95201 <br /> (209) 468—&44•?--'54-',)0 <br /> PE_RUIT FYPIRES 1 YEAR FROM DATE ISSUED I <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 ccupllance with San Joaquin County Ordinance No. 549 and 1862 azo! the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> `� � <br /> Job Address _7x Q r p` O��S gC1 • — city �� Lot Size/Acreage <br /> Owner's Name T� e P�-G��.�� Address Q l^ O �' LcA <br /> - Phone 2a t Z <br /> 34/� J- cense No.cN6viEu/�+. �yr��e"D 30�`ll Pnone��b 7Y5 C <br /> Contractor �C yL//< D�[/aN6 Address L v <br /> TYPE OF WELL/PUMP. NEW WELL O WELL REPLACEMENT O DESTRUCTION O Out of Service Well O C <br /> PUMP INSTALLATION O SYSTEM REPAIR O OTHER O Monitoring Well X C <br /> DISTANCE TO NEAREST: SEPTIC TANK 7� SEWER LINES -7 S"G r DISPOSAL FLO. O PROP. LINE Z7 , <br /> FOUNDATION 7 Sc AGRICULTURE WELL 7 C OTHER WELL 7 SO PITS/SUMPS 2:-'L� <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS .. \' <br /> M Industrial O Open Bottom O Manteca Dia. of Well Excavation l Dia. of Well Casing _ <br /> U Domestic/Private }F> Gravel Pack Tracy Type of Casing PQ C- Specifications 90 rde <br /> M Public Cl Other O Delta Depth of Grout Seal 5'-4,r k-,,e - `21 Type of Grout C <br /> ❑ ImUstion —Approx. Depth O Eastern Surfics Seal Installed by N \,{r t <br /> Repair Work Done v Type of Pump /—J H.P. State Work Done _ <br /> Well Destruction O Well Diameter H " Sealing Material i Depth Re Lac-i k S 3- 5 -.5— r T <br /> Depth - 90 Tiller Material L Depth Tt ) (- -, a ,ck l;- .5,5- <br /> TYPE <br /> STYPE OF SEPTIC WORK: NEW INSTALLATION D REPAIR/ADDITION 0 DE$,1 CjiQ�+:1,�f septic system permuted if public sower is <br /> rrAATT��JJ�N ilable within 200 feet.) <br /> Installation will serve: Residence _ Commercial_ Other -- RECEIVED � <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: MAY 2 1 1992 water table depth <br /> SEPTIC TANK O Type/Mfg Ca$MX10A l IIN Col l INW. Compartments <br /> PKG. TREATMENT PLT. O PUBLIC HEALTH SERVI"$,od of Disposal <br /> ENY,IRONMENTAL HEAbT�VIg4N <br /> Distance to nearest: Well Foun at on r y <br /> LEACHING LINE Cl No. b Length of lines Total length/size <br /> c <br /> FILTER BED (_I Distance to nearest: Well Foundation Property Line <br /> C <br /> SEEPAGE PITS 11 Depth Size Number r <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS O <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 C <br /> C <br /> rules and regulations of the San Joaquin County <br /> Home owner or licensed agent's signature certifies the following: "I comity 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 subcontracting signature <br /> certifies the following: "I certify that in the perlormance 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 ust iced inspections. Complete drawing on reverse side. f <br /> r <br /> Signed X Title C�e 'U}1 S�' Dole: <br /> sof Z( �Z <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date ( � Area -p r/ <br /> � CJ /7 y <br /> Pit or Grout Inspection by ( 11 Date Y Final Inspection by t Date <br /> A <br /> Additional Comments: <br /> Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES V /Jt <br /> 445 N SAN JOAQUIN, P O BOX 2009, STOCKTON, CA 95201 <br /> FEE AMOUNT DUE AMOJNT REMITTED CK s RECEIV 0 BY DATE PERMIT V0. <br /> INFO CASH <br /> EH 13.74 iaty res, R 7 .0U �`7, �� /o1!7 /V ,. I ����i�? 2--2,0 <br />
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