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88-1370
EnvironmentalHealth
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21474
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4200/4300 - Liquid Waste/Water Well Permits
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88-1370
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Last modified
11/29/2019 10:06:31 PM
Creation date
12/3/2017 12:32:48 AM
Metadata
Fields
Template:
EHD - Public
ProgramCode
4200/4300 - Liquid Waste/Water Well Permits
RECORD_ID
88-1370
STREET_NUMBER
21474
Direction
N
STREET_NAME
MANN
STREET_TYPE
RD
City
ACAMPO
SITE_LOCATION
21474 N MANN RD
RECEIVED_DATE
05/31/1988
P_LOCATION
CHARLES STARR
Supplemental fields
FilePath
\MIGRATIONS\M\MANN\21474\88-1370.PDF
QuestysFileName
88-1370
QuestysRecordID
1840005
QuestysRecordType
12
Tags
EHD - Public
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` APPLICATION FOR PERMIT 11100 <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 /> i 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 _/1 1 City Lot Size PM <br /> [ /�Q�.� Lr's dress Phone a <br /> Owner's Name. � 7 ���d <br /> Contractor i Address-f *•�� l� 4t_ c ..- - License No.cMg3 2 �k_Pfione �'a <br /> I <br /> -,J-TYPE OF WELL/PUMP: r' NE ELL- WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> 3 PUMP INSTALLATION _ SYSTEM REPAIR ❑ OTHER ❑ _ <br /> r DISTANCE TO NEAREST: SEPTIC TANK I ' 1 <br /> _��— SEWER LINES DISPOSAL FLD. PROP. LINE <br /> i F } FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPSJ_ tw <br /> i INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS I <br /> i 1r i <br /> ❑ Industrial pen Bottom ❑ Manteca 1 Dia. of Well Excavation- Dia. of Well Casing <br /> omestic/Private (] Gravel-Pack ❑ Tracy. Type of Casing rP�J Specifications �t <br /> f (-I Public 71 Other Cl Delta Depth of Grout Seal , j Type ofout SC�tYtGh i_ <br /> I I Irrigation _.-Approx. Depth {�"I Eastern S`j`�ace Seal Installed by 5/ 1. _ <br /> sRepair Work Done L7 Type of Pump sV H.P. E ./ate State Work Done <br /> Well Destruction ❑ Well Diameter t Sealing Material [top 50'1 [ <br /> Depth f Filler Material (Below 50'1 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR-/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is r <br /> r ` available within 200 feet.( ! <br /> Installation will serve: Residence_ Commercial " Other f <br /> k 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 /> r. Distance to nearest: Well Foundation Property Line <br /> 44.. I <br /> k <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> t 'FILTER BED--� sY`❑ Distance to nearest: Well Foundation Property Line ' <br /> r <br /> r <br /> SEEPAGE PITS ti C1 Depth Size _ Number _ r <br /> SUMPS Cl 7Distance to nearest: Well 3 Foundation Property Line <br /> F1f j I <br /> DISPOSAL PONDS `" — -„ .... -�..� , ;.�. �.•.,�:,-, .., - <br /> I hereby certify that I have prepared this application and that the wo'rk/Aill be done in accordan 6`with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the.San Joaquin Local.,Health District. I i <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 /> i 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 /> J certifies the following: "I certify that ill the'pI rformance of the work for which this permit is issued,I_shall employ persons subject to workman's compensa- <br /> tion laws of California." p <br /> The applicant must call for all required inspections. Complete drawing en reverse side. <br /> Signed X rr� /1n." Title: Date: 3 z <br /> DEPARTMENT USE ONLY <br /> Application Accepted by Date Area <br /> Pit or Grout inspection by r Daf�? Z t Final Inspection ate <br /> t Additional Comments: t <br /> t ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6365 <br /> --i ApplicantT Return_all.,copies to:,.Environmental.Health.-P,ermit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95241 <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED CCASH K if <br /> 1gEV.i/K51 RECEIVED BY DATE PERMIT 0, <br /> + EH 13.24 I <br /> I EH 14.211 <br /> L 4 <br />
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