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89-700
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4200/4300 - Liquid Waste/Water Well Permits
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89-700
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Last modified
1/9/2020 10:09:27 PM
Creation date
12/2/2017 9:39:30 PM
Metadata
Fields
Template:
EHD - Public
ProgramCode
4200/4300 - Liquid Waste/Water Well Permits
RECORD_ID
89-700
STREET_NUMBER
2520
Direction
E
STREET_NAME
LINDSAY
City
STOCKTON
SITE_LOCATION
2520 E LINDSAY
RECEIVED_DATE
04/05/1989
P_LOCATION
FISHER
Supplemental fields
FilePath
\MIGRATIONS\L\LINDSAY\2520\89-700.PDF
QuestysFileName
89-700
QuestysRecordID
1821970
QuestysRecordType
12
Tags
EHD - Public
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f,r <br /> I <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT S <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 he+eby 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 h S� � 6, /6 1 < lav City Lot N7.Fr. Lot Size PM <br /> Owner's Name P,�J. +---,',—- Address Phone Al <br /> Contractor j�- 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. UNE <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 q- 1 <br /> * Public ❑ Other Cl Delta Depth of Grout Seal Type of Grout C� <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 50') <br /> Depth Filler Material 18elow 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIR/ADDITION I I DESTRUCTION 1 INo 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 j <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED. ❑ Distance to nearest: Well Foundation Property Line hh_ <br /> �4 <br /> SEEPAGE PITS i I Depth Size Number <br /> SUMPS Ll 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 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 all required inspections. Complete drawing on reverse side. <br /> f Signed X Title: ; _ _i Date: —4i <br /> ( H D MENT USE ONLY <br /> Application Accepted by :r Date Area <br /> Pit or Grout inspection by Date Final Inspection by ~ t Date 41 1 <br /> Additional Comments: 7 J /1 <br /> ❑ Stk 466-6781 ❑ Lodi 369-36A ❑ 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 95201FEE <br /> {� <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH CK 9 RECEIVED BY DATE PERMIT"NO. r <br /> i F <br /> + EH 14-14�2a V291REV.1/85Y <br /> EH � �� 7© � <br /> - <br /> S <br />
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