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88-260
EnvironmentalHealth
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HARLAN
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4200/4300 - Liquid Waste/Water Well Permits
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88-260
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Entry Properties
Last modified
12/7/2019 10:54:25 PM
Creation date
12/2/2017 2:36:20 PM
Metadata
Fields
Template:
EHD - Public
ProgramCode
4200/4300 - Liquid Waste/Water Well Permits
RECORD_ID
88-260
STREET_NUMBER
14282
STREET_NAME
HARLAN
City
LATHROP
SITE_LOCATION
14282 HARLAN
RECEIVED_DATE
02/09/1988
P_LOCATION
PERRY TURNER
Supplemental fields
FilePath
\MIGRATIONS\H\HARLAN\14282\88-260.PDF
QuestysFileName
88-260
QuestysRecordID
1743777
QuestysRecordType
12
Tags
EHD - Public
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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 # <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED NDU-�LX <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. / f <br /> Job Address ___( �L�, 34�4.kl A-- - city 4.,o PGLot Size PM <br /> f�L~ Li [� t r <br /> Owner's Name I- T 1� Address I Phone <br /> Contractor L'C_ Address_- s ��____License No Phone <br /> TYPE OF;WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> --'—^-PUMP INSTALLATION-❑- - -^-SYSTEM REPAIR ❑ OTHER'D <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 /> ❑1ndustrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Groutr <br /> ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by,,' <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top'50') r r <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTIONX(No septic system permitted if public sewer is <br /> t available within 200 feet.) <br /> Installation will serve: Residence_ Commercial_ Other <br /> Number of living units: Number of bedrooms <br /> Character of, <br /> soil-to a depth of 3 feet: Water table depth <br /> SEPTIC TANK �4�f. ❑ ,Type/Mfg CapacityNo. Compartments <br /> PKG. TREATMENT'PLT. ❑ �'1 - Method of Disposal <br /> '`Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No: &Length of lines Total lerigth/size /t\� <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS, ❑ Depth Size r Number <br /> SUMPS i ❑ Distance to nearest:..,.._.WelI =s Foundation Property Line �1 <br /> DISPOSAL PONDS. Lj _. <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 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,I shall employ persons subject to workman's compensa- <br /> tion laws of California." " <br /> The applicant must call for al required inspections. Complete dawing on reverse side. <br /> Signed XxTitle: Date: �- <br /> J <br /> R DEPARTMENT USE ONLY <br /> Application Accepted by c k�<'1Rn C� MA r—.._. Date Area <br /> Pit or Grout Inspection by {� Date Final Inspection by 1 Date <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 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 /> CK <br /> + AMOU� NT DUE ; AMOUNTREMITTED VED BY DATE PERMIT'NO.INF ASH <br /> EH 13.241REV.t/957 66 33,., <br /> EH 14.28 lJ" <br />
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