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88-1059
EnvironmentalHealth
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EHD Program Facility Records by Street Name
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99 (STATE ROUTE 99)
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11350
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4200/4300 - Liquid Waste/Water Well Permits
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88-1059
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Last modified
11/19/2024 1:53:57 PM
Creation date
12/3/2017 4:29:50 AM
Metadata
Fields
Template:
EHD - Public
ProgramCode
4200/4300 - Liquid Waste/Water Well Permits
RECORD_ID
88-1059
STREET_NUMBER
11350
Direction
N
STREET_NAME
STATE ROUTE 99
City
LODI
SITE_LOCATION
11350 N HWY 99
RECEIVED_DATE
4/29/88
P_LOCATION
CRAIG LEWIS
Supplemental fields
FilePath
\MIGRATIONS\N\99 (HWY99)\11350\88-1059.PDF
QuestysFileName
88-1059
QuestysRecordID
1878865
QuestysRecordType
12
Tags
EHD - Public
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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> 2. <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 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, AC <br /> Job Address �!3 S O City Lot Size l PM <br /> Owner's Name Address J /��f y�P^hone .36 <br /> • �` 17 License No��33S Phone 3 7 2� <br /> Contractor Address <br /> TYPE OF WELL/UMP: NEW WELL)K <br /> WELL REPLACEMENT DESTRUCTION <br /> PUMP INSTALLATION I SYSTEM REPAIR ❑ OTHER ❑ �— <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 SPECIFICATI S Qr <br /> ❑ Industrial G1 Open Bottom El Manteca Dia. of Well Excavation .1 a Dia. of Well Casing <br /> 'J:_d'Domestic/Private 'Gravel Pack ❑ Tracy Type of Casing /04/C Specifications C <br /> Public r Other ❑ Delta Depth of Grout Seal /o D Type of Grout__CX JWef'r <br /> I i Irrigation _-Approx. Depth I I Eastern Surfape Seal Installed by (fo_.&✓ jii�A, <br /> Repair Work Done U Type of Pump S'V H.P. State Work Done <br /> n <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50') <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I 1 DESTRUCTION l I INo septic system permitted if public sewer is <br /> available within 200 feet.I <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 n <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS l I Depth Size _ Number <br /> SUMPS C1 Distance to nearest: Well Foundation 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 ordinances, state laws, and <br /> 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 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//must II for all required inspections. Complete drawing on reverse side. <br /> Signed X C Title: Date: 'r—M <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by d L Date f Area <br /> Pit or Grout Inspection by D R t,957-4-44,Einal Inspection by Dat <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 104 a y '833MM9'_' 56 O " <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 I CK 11 RECEIVED BY DATE PERMIT-NO. <br /> INFO CASH <br /> + EH 13-24(REV.i/m5) <br /> EH 14-28 Q <br /> �, I <br />
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