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90-3309
EnvironmentalHealth
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4200/4300 - Liquid Waste/Water Well Permits
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90-3309
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Last modified
3/3/2020 10:15:48 AM
Creation date
12/2/2017 6:59:38 PM
Metadata
Fields
Template:
EHD - Public
ProgramCode
4200/4300 - Liquid Waste/Water Well Permits
RECORD_ID
90-3309
PE
4210
STREET_NUMBER
1E004
STREET_NAME
KEYSTONE
City
TRACY
SITE_LOCATION
30000 KASSON RD - 1E004 KEYSTONE
RECEIVED_DATE
12/13/1990
P_LOCATION
MERLE ENFIELD
Supplemental fields
FilePath
\MIGRATIONS\K\KASSON\30000\KEYSTONE\1E004\90-3309.PDF
QuestysFileName
90-3309
QuestysRecordID
1803303
QuestysRecordType
12
Tags
EHD - Public
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p� APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON 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. <br /> Job Address ^3a� �iQSSOI►' ridr — 1E11 feE`{S7adt�y,/ '/� TSS Lot Size PM <br /> Owner's Name 'L L`�° E� e�p Address 4&7 yT]GYST�/✓� Phone 6 O <br /> Contractor /Y OXY � /Y Address 00.4 Lv O 14 V6 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 /> 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 /> FI Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation ..Approx. Depth I I 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 501 <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I1 REPAIR/ADDITION DESTRUCTION I I (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence E Commercial_ Other <br /> Number of living units: ._ Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth S� <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ eon N, / Method of Disposal <br /> Distance to nearest: Wellnfbundation 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 Z .V/ _ Number l <br /> SUMPS 9 Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> 1 hereby certify that l 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 c for all required inspections. Complete drawing on reverse side. <br /> Signed X a 6 Title: Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date 3 . Area <br /> Pit or Grout Inspection by Date Final Inspection by ate <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 /> INFO FEE AMOUNT DUE AMOUNT REMITTED /CQK RECEIVED 8Y / DATE PERMITNO. a <br /> a EH 3-24(REV.1/Hs) / " C �I / o� l /.J� �� / ����� 9Q r (J <br /> EH 14-26 <br />
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