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83-276
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4200/4300 - Liquid Waste/Water Well Permits
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83-276
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Last modified
8/4/2019 11:34:01 PM
Creation date
12/1/2017 12:40:02 PM
Metadata
Fields
Template:
EHD - Public
ProgramCode
4200/4300 - Liquid Waste/Water Well Permits
RECORD_ID
83-276
STREET_NUMBER
13806
Direction
N
STREET_NAME
WELLS
STREET_TYPE
LN
City
LODI
SITE_LOCATION
13806 N WELLS LN
RECEIVED_DATE
4/25/1983
P_LOCATION
JAMES EVANS
Supplemental fields
FilePath
\MIGRATIONS\W\WELLS\13806\83-276.PDF
QuestysFileName
83-276
QuestysRecordID
1981570
QuestysRecordType
12
Tags
EHD - Public
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APPLICATION FOR PERMiT awl <br /> SAN JOAQU-IN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. YJ" <br /> Telephone (209) 466-6781 <br /> DATE ISSUED <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 <br /> described. This application is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump <br /> and the Rules and Regulations of th San Joaquin Local Health District, <br /> Job Addressitz Subdivision Name <br /> Owner's Name !Address �,�-w• Phohe <br /> Contractor's NJW. License No. p�-7d/ <br /> TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT DESTRUCTION U W <br /> PUMP INSTALLATION SYSTEM REPAIR OTHER U } <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> 1J Industrial U Open Bottom r_�Manteca Dia. of Well Excavation <br /> U Domestic/Private ❑ Gravel Pack 11 Tracy Dia. of Well Casing <br /> Public F-1 Other L] Delta Type of Casing <br /> V Irrigation Approx. EJ Eastern Specifications <br /> ❑Cathodic Protection Depth <br /> Geophysical Depth of Grout Seal <br /> 17 Type of Grout <br /> Other <br /> Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction U Well Diameter Sealing Material (top 50`) <br /> Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION LI REPAIR/ADDITION (No septic tank or seepage pit permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence Commercial Other <br /> Number of living units: I Number of bedrooms ;? Lot size <br /> Character of soil to a depth of 3 feet: '�]y� 4a,g,r4, Water table depth O rl <br /> SEPTIC TANK Type/Mfg � ,% Capacity ��[)�_ No. .Compartments <br /> PKG. TREATMENT PLT. E] Type/Mfg Capacity Method of Disposal <br /> SEWAGE SYSTEM Distance to nearest: Well Foundation �f - Property Line <br /> DESTRUCTION <br /> LEACHING LINE U No. & Length of lines l^JAS-r Total length/size <br /> FILTER BED Distance to nearest: Well —AI Foundation J6 I Property Line /40 f <br /> SEEPAGE PITS Depth a 5- Size -3,P"r Number Z <br /> SUMPS , �� Distance to nearest: Well Foundation+ t© 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 <br /> ordinances, state laws, and 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 <br /> permit is issued, I shall not employ any person in such manner as to become subject to workmant compensation laws of California." <br /> Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work for which <br /> this permit is issued, I shall/e[ruplov persons subject to workman's compensation laws of California." <br /> The app1 ca calor e ired inspections. Complete drawing on reverse side. <br /> Signed X Title: A,— Date; �3 <br /> FOR DEPARTMENT USE ONLY <br /> App kation Accepted by JAreaJ Stk 466-67$1 <br /> Additional Comments: o ?t? Lodi 369-3621 <br /> Pit or Grout Inspection by A date Manteca 823-7104 <br /> Final Inspection by Date "'❑ Tracy 835-6385 <br /> Applicant - Return all copies o: Fnviro m ntal Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CR 95201 <br /> z <br /> FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. <br /> INFO <br /> EH 13-24 REV. 10/$214 A,'� ice' 10/82 500 <br /> 14-25 111 ���� <br /> " 1 <br />
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