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2900 - Site Mitigation Program
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PR0009040
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Last modified
10/1/2019 4:54:39 PM
Creation date
10/1/2019 4:48:55 PM
Metadata
Fields
Template:
EHD - Public
ProgramCode
2900 - Site Mitigation Program
File Section
FIELD DOCUMENTS
RECORD_ID
PR0009040
PE
2960
FACILITY_ID
FA0004009
FACILITY_NAME
CALIFORNIA FUELS/D ATWATER
STREET_NUMBER
838
STREET_NAME
MOKELUMNE
STREET_TYPE
ST
City
WOODBRIDGE
Zip
95258
APN
01509082
CURRENT_STATUS
01
SITE_LOCATION
838 MOKELUMNE ST
P_LOCATION
99
P_DISTRICT
004
QC Status
Approved
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EHD - Public
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t <br /> r APPLICATION FOR PERMIT 1 <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZETON AVE., STOCKTON, CA <br /> Telephone (209) 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. L ` <br /> Job Address =) -' 5 0',G I4 MNc% �J t' �7 City WloL l .- 4 Lot Size PM <br /> Owner's Name CIS It Car,v.t* P(,i �5 Address 1•L �t;x � z U�I S E c0c..; Phone Z`1�1` L-6- S9 Z <br /> F d G- �� PC Pr 3 v 6s. <br /> Contractor ��%� n7c= "t/j-c�wA�e- � +Address i-�� x �� r �' License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHERSa� QO" ,S <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 b" Dia. of Well Casing <br /> Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Ci Specifications <br /> ("1 Public Vr Other Sc;1�ion'nc� 11 Delta Depth of Grout Seal _32- Type of Grout + � } <br /> I I Irrigation 32-f Approx. Depth 1 I Eastern Surface Seal Installed by -3 T, _ <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done_ <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 .lJ <br /> Depth 3 Filler Material (Below 501 — <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 1 I REPAIR/ADDITION 1 1 DESTRUCTION I I (No 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 <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 ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS I I Depth Size Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <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 Di§trict. <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 followin *"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 Califor ia." <br /> The applicant mu ca for inspections. Complete drawing on reverse side. <br /> Signed Title: �f°�tT �'�1�-1�2. Date: h-3 _cl 2 <br /> 9 —� <br /> FOR DEPARTMENT USE ONLY q S'3 (,, <br /> Application Accepted by M ,I i� Date I' 1 Area 2� `�' <br /> Pit or Grout Inspection by / ' Date�L•9�f� Final Inspection by Date <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ 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 /> FEE IAMO�UNT�DUE AMOUNT REMITTED CA'SH�Q RECEIVED BY DATES 7Z- <br /> EH <br /> PERmrr'�NOO.. <br /> INFO I— �� V4�L.1�1 II''� / +Z`r '✓) <br /> � EH 13241REV.lixsi <br /> EH 1428 <br />
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