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89-2525
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4200/4300 - Liquid Waste/Water Well Permits
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89-2525
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Last modified
12/30/2019 10:11:40 PM
Creation date
12/1/2017 12:02:23 PM
Metadata
Fields
Template:
EHD - Public
ProgramCode
4200/4300 - Liquid Waste/Water Well Permits
RECORD_ID
89-2525
STREET_NUMBER
2361
STREET_NAME
WATERLOO
STREET_TYPE
RD
City
STOCKTON
SITE_LOCATION
2361 WATERLOO RD
RECEIVED_DATE
10/12/1989
P_LOCATION
KENNETH H SEVERIN
Supplemental fields
FilePath
\MIGRATIONS\W\WATERLOO\2361\89-2525.PDF
QuestysFileName
89-2525
QuestysRecordID
1978085
QuestysRecordType
12
Tags
EHD - Public
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APPLICATION FOR PERMIT IW" l <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT 0 <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA C <br /> �D <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. ` /f�f -� / <br /> Job Address3f� W sem_!!l City Lot Size PM <br /> /Y Owner's Name nj/ /� Phone 7'4_sr�-2 <br /> kA <br /> Contractor t: e Address License No. Phone_ <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ - 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 /> I <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS p <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> � W <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> Public Fl . I {-1 Delta <br /> I I Depth of Grout Seal Type of Grout <br /> Irrigation ___Approx.'Depth i I Eastern Surface Seal Installed by <br /> ReRepair Work Done ❑ T p <br /> p Type of Pum H.P. State Work Done <br /> Well Destruction ❑ Well Diameter. Sealing Material Itop 50'1 <br /> Depth Filler Material (Below 50') _ <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION l I DESTRUCTIO 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 /> I <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS l I Depth ` Size _ Number <br /> SUMPS Cl Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ 1 <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 Joaquid 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." 11 <br /> The applica t st call fo a re u' d ins ons. Complet%drawing on reverse side. <br /> 1 <br /> Signed Title: Date:/Z2 — �Z Y4 <br /> FOR DEPARTMENT USE ONLY ; <br /> Application Accepted by Date Area <br /> Pit or Grout Inspection by Date Final Inspection by ' rel Date 4 <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6365 i <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Ha2elton Ave., P.O. Box 2009, Stk., CA 95201 i <br /> I <br /> FEE INFO AMOUNT DUE AMOUNT REMIpTT�ED CK RECEIVED BY DATE PERMIT'NO. <br /> +.EH1 -241REV.5/H51 (Z� <br /> EH 144-29 I V I <br />
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