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91-0503
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4200/4300 - Liquid Waste/Water Well Permits
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91-0503
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Last modified
3/11/2020 9:29:03 PM
Creation date
12/2/2017 10:18:13 PM
Metadata
Fields
Template:
EHD - Public
ProgramCode
4200/4300 - Liquid Waste/Water Well Permits
RECORD_ID
91-0503
STREET_NUMBER
15405
Direction
N
STREET_NAME
LOCUST TREE
STREET_TYPE
RD
City
LODI
SITE_LOCATION
15405 N LOCUST TREE RD
RECEIVED_DATE
03/01/1991
P_LOCATION
BEN GOEHRING
Supplemental fields
FilePath
\MIGRATIONS\L\LOCUST TREE\15405\91-0503.PDF
QuestysFileName
91-0503
QuestysRecordID
1826330
QuestysRecordType
12
Tags
EHD - Public
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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION 6,t) I-v" <br /> 1601 E. HAZELTON AVE. , PHONE (209)46$-3420 <br /> P 0 BOR 2009, STOCKTON, CA 95201 <br /> PXRMIT EXPIRES 1 YEAR FROM DAIE 15SUED <br /> (Complete in Triplicate) <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work herein described. This <br /> application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> Job Address 15405 N. LOcudarepa Rd _ _-_ City Lodi Lot Size/Acreage _'45 ar•rec <br /> Owner's Name Ben GOehring Address gamp Phone11-1-05-41 <br /> Contractor Clark Well , InC Address License No. 371 560 Phone <br /> TYPE OF WELL/PUMP:. NEW WELL ❑ WELL REPLACEMEN'IX® OESTRUCTIObtKkOut of Service Well ❑ <br /> PUMP INSTALLATION V SYSTEM REPAIR ❑ OTHER C3 Monitoring Well C7 <br /> DISTANCE TO NEAREST: SEPTIC TANK 90 r SEWER LINES DISPOSAL FLD. PROP. LINE 100 <br /> FOUNDATION AGRICULTURE WELL OTHER WELL 50 PITS/SUMPS — J <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> n <br /> C) Industrial ❑ Open Bottom ❑ Manteca Pia. of Well Excavation Dia. of Well Casing .b 5 <br /> XP.14omestic/Private X:&Mravel Pack L1 Tracy Type of Casing Steel Specifications,#10 ` <br /> I"I Public I1 Other r-1 Delta Depth of Grout Seal 200 i Type of Grouts sack <br /> i I irrioation ____.Approx. Depth I I Eastern Surface Seal Installed by Clark <br /> Repair Work Done ❑ Type of Pump Sub H.p. 5 State Work Done ins-ta 11 <br /> Well Destruction Kiiff Well Diameter Sir Sealing Material & Depth 1 0 r fi I 1 wi th Q sack from <br /> Depth Filler Material & Depth bottom to to <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I i 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 O Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PET. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line (� <br /> LEACHING LINE D 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 I <br /> SUMPS Ll Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS 1:1 <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 Joaquin County <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: '9 certify that in the performance of the worts for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant t it fall eatie r ons. mplete drawing on reverse side. <br /> Signed TitleVP-Clark Well Inc. Date. 1 MarcH 91 <br /> N4ENT USE ONLY { a <br /> Application Accepted by I Al <br /> Jr�� •-^-s Date L� `\ Area <br /> Pit or ro Inspection by " TSe Final Inspection by Date <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public. Health <br /> Services, Environmental Health Permit/Services <br /> 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE ?ERMI7'N0, <br />
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