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92-3676
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4200/4300 - Liquid Waste/Water Well Permits
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92-3676
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Entry Properties
Last modified
4/8/2020 10:08:02 PM
Creation date
12/1/2017 12:40:22 PM
Metadata
Fields
Template:
EHD - Public
ProgramCode
4200/4300 - Liquid Waste/Water Well Permits
RECORD_ID
92-3676
STREET_NUMBER
14501
Direction
N
STREET_NAME
WELLS
STREET_TYPE
LN
City
LODI
SITE_LOCATION
14501 N WELLS LN
RECEIVED_DATE
11/10/1992
P_LOCATION
JIM BLINCOE
Supplemental fields
FilePath
\MIGRATIONS\W\WELLS\14501\92-3676.PDF
QuestysFileName
92-3676
QuestysRecordID
1981606
QuestysRecordType
12
Tags
EHD - Public
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"SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <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 HealtF <br /> ice r ti`` YJab Address �� _ ^,,,,,,,, ,,,,,,,_,,,,,__,_� City Lot Size/Acreage? } D�`l <br /> t t , <br /> oe <br /> Owner's Name � �T��+�� Address Phone / I <br /> Contractorress License No. Phone v <br /> TYPE OF WELL/P MP: NEW WELL ❑ WELL REPLACEMENT DESTRUCTION o Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR C1 OTHER ❑ Monitoring Well <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS .T p <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONSU�-yy <br /> n Industrial C1 Open Bottom 0 Manteca Dia. of Well Excavation Dia. of Well Casing `J <br /> [.] <br /> Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications <br /> I'1 Public fa Other 177 Delta Depth of Grout Seal Type of Grout <br /> t I Irrigation �.Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done LJ Type of Pump N.P. State Work Dane _ <br /> Well Destruction ❑ Well Diameter Sealing Material 8 Depth <br /> Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I drREPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is <br /> / available within 200 feet.l <br /> Installation will serve: Residence .-4 Commercial_ Other <br /> Number of living units: __4_ Number of b rooms <br /> Character of soil to a depth of 3 feet: �� Fater table depth <br /> SEPTIC TANK 0 Type/Mfg Capacity_ No. Compartments <br /> PKG. TREATMENT PLT. ❑ i Method of Digposal <br /> Distance to nearest: Well 106 4-- Foundationr�D t Property Line <br /> F <br /> LEACHING LINE ❑ No. & Length of lines Total length/size 770 <br /> FILTER BED n Distance to nearest: Well �o Foundation -u-r V- Property Line <br /> SEEPAGE PITS 11 Depth I X 1 19 X M4. Number <br /> P LI Distance to nearest: Well Foundation C Property Line N <br /> D POSAL 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 /> �f7 <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: "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 m 11 fa all r uired ins s. Complete dra . g on reverse side. <br /> Signed Title: _ _f eG - Date: <br /> OR EPARTMENT USE ONLY / 1� �1 <br /> Ap ication Accepted by U Date f l' 12Z Areal__Q �c P_ <br /> rrot Inspection by Date a Final Inspection by 6 Date I� J <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 <br /> FEE <br /> CK <br /> INFO] AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY / DATE <br /> +�j [�PERMIT'NO. <br /> . EH14-24IREV.rinSt�IVIlk t01r1 Q.f �l^ry f� /.2 — �j <br /> EH t3-2a ` <br /> '~y r <br />
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