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91-0262
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4200/4300 - Liquid Waste/Water Well Permits
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91-0262
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Last modified
3/11/2020 9:34:09 PM
Creation date
12/1/2017 12:42:22 PM
Metadata
Fields
Template:
EHD - Public
ProgramCode
4200/4300 - Liquid Waste/Water Well Permits
RECORD_ID
91-0262
STREET_NAME
WEST LN & EIGHT MILE
STREET_TYPE
RD
City
STOCKTON
SITE_LOCATION
WEST LN & EIGHT MILE RD
RECEIVED_DATE
02/01/1991
P_LOCATION
E W LEBARON
Supplemental fields
FilePath
\MIGRATIONS\W\WEST\0\91-0262.PDF
QuestysFileName
91-0262
QuestysRecordID
1982274
QuestysRecordType
12
Tags
EHD - Public
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ii <br /> It APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> I <br /> PERMIT EXPIRES ('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 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. V1 <br /> Job Address Corner of West :Lane; & Eight Mile, Road City Stockton Lar Size 235 Acres PM <br />` Owner's Name, E• W. LEBARON Address 2308 Cabrillo Circle Lodi Ca Phone 209=368-2380 <br /> Contractor Burton Ce Shoup Aadress 4860 Harvest Road Aram gicense No. 376764 Phone 368-3343 <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION �J SYSTEM REPAIR OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <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 />'i ❑ Domestic/Private Cl Gravel Pack_ 171 Type.of Casing Specifications <br /> Ll Public ❑4Other _ Ll Delta Depth of Grout Seal Type of Grout _ <br /> t Irrigation °._Approx. Depth I l-Eastern Surface_ Seal Installed by- <br /> Repair Work Done LJType of Pump TUrbdMe - H.P. _75' 2P —__ State Work Done Pill aut cotnnlete <br /> Well Destruction ❑ We.1I Diameter Sealing Material Itop 501 PSP 3ZKMM Reinstall 17uap 130ISett ng <br /> Depth I`7$ Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION i 1 REPAIR/ADDITION i I DESTRUCTION I I (No septic system permitted if public.sewer is <br /> available within 200 feet.) <br /> Installation will sere: Residence_ Commercial_ Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth:of 3 feet: ''" —Water table depth I <br /> f SEPTIC TANK ❑ .Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ h Method of Disposal <br /> _ �. <br /> Distance to nearest: Wel! Foundation Property.Line <br /> I LEACHING LINE ❑ No. & Length of tines Total length/size <br /> FILTER BED ❑ ".Distance toynearest: Well Foundation Property Line <br /> SEEPAGE PITS I 1a ,Depth Size Number <br /> ,SUMPS L�' "Distance to nearest:' T 'Well' Foundation _ --"Property Line ' <br /> i DISPOSAL PONDS ❑ x <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 ner 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 /> oy 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 workJor which this permit is issued,I shall employ persons subject to workman's compensa- <br /> tion Jaws of California." ;p <br /> The applica ust call or all required inspecti s. Complete drawing on reverse side. <br />! 1 Contracicrx y" 4 Date: 2-1-91 <br /> l Signed Title: <br /> R DEPARTMENT USE ONLY <br /> Application Accepted by Date 1 Area <br /> . .jy <br /> Pit or Grout Inspection,by ,I Date Final Inspection by Date <br /> 0 CJ <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ 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 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK CASH RECEIVED 9Y DATE PERMIT'NO. <br /> INFO i �(��(�\ 1 <br /> * EH <br /> EH 1p281REV.tin57 ueO� �s�• I 1 r `� l.[t <br />
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