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83-1094
EnvironmentalHealth
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EHD Program Facility Records by Street Name
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99 (STATE ROUTE 99)
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13063
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4200/4300 - Liquid Waste/Water Well Permits
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83-1094
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Last modified
11/19/2024 1:53:40 PM
Creation date
12/3/2017 4:39:36 AM
Metadata
Fields
Template:
EHD - Public
ProgramCode
4200/4300 - Liquid Waste/Water Well Permits
RECORD_ID
83-1094
STREET_NUMBER
13063
Direction
N
STREET_NAME
STATE ROUTE 99
City
LODI
SITE_LOCATION
13063 N HWY 99
RECEIVED_DATE
10/3/83
P_LOCATION
CAROL SQUIRES
Supplemental fields
FilePath
\MIGRATIONS\N\99 (HWY99)\13063\83-1094.PDF
QuestysFileName
83-1094
QuestysRecordID
1877883
QuestysRecordType
12
Tags
EHD - Public
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APPLICATION FOR PERMIT r^ 04t) <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT f J �^- div <br /> n 1601 E. HAZELTON AVE., STOCKTON, CA ~ <br /> Telephone (209) 466-6781 �•� C''r PERMIT N0. <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED / 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 the San Joaquin Local Health District. <br /> Job Address 3 Q 1 &uLda � Name 1C _ �� .�� <br /> Owner's Name Address r 3 Y <br /> Phone <br /> Contractor's Name AG-) f. License No. 2 Phone 3 _� / <br /> TYPE OF WELL/PUMP WORK: NEW WELL [] WELL REPLACEMENT DESTRUCTION <br /> PUMP INSTALLATION SYSTEM REPAIR OTHER [J <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL PLO. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> I I Industrial U Open Bottom [] Manteca Dia. of Well Excavation <br /> Domestic/Private (�Gravel Pack L] Tracy Dia, of Well Casing <br /> T Public �j Other Delta �! <br /> Irri ation Type of Casing <br /> V g Depth <br /> ❑ Eastern Specifications <br /> Cathodic Protection p J <br /> Geophysical <br /> Depth of Grout Seal <br /> Other <br /> Type of Grout a <br /> Surface Seal Installed by 1; <br /> Repair Work Done Type of Pump H.P. State Work Done�c.�-G�, .��jy,� � <br /> Well Destruction U Well Diameter Sealing Material (top 50') <br /> Depth Filler Material {Below 50'} ` <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION U (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: Number of bedrooms Lot size <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK Type/Mfg Capacity No. Compartments AV I <br /> PKG. TREATMENT PLT, Type/Mfg Capacity Method of Disposal <br /> SEWAGE SYSTEM Distance to nearest: Well Foundation Property Line . <br /> DESTRUCTION <br /> LEACHING LINE [J No. & Length of lines Total length/size <br /> FILTER BED Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS ❑ Depth Size Number <br /> SUMPS L-1 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 <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 workman 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 i <br /> this permit i issued, I shall employ persons subject to workman's compensation laws of California." L <br /> The applica mus call fo all required nspectiors �Complet r wing on reverse side. <br /> i ii <br /> Signed X _ tle: /L� Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted Area &-nteca <br /> k 466-6781 f <br /> Additional Comments Jnr q y a di 369-3621 f ` <br /> Pit or Grout Inspection b Date 823-1104 <br /> Final Inspection by 4,0k Date ❑ Tracy 835-6385 <br /> Applicant - Return all copies to: Env nmental Health Permit/Services 1670 If E, H zelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. <br /> INFO <br /> �1 = c-,o <br /> EH 13-24 REV. 10/8 1 50 <br /> a^ j } 8Z O <br /> 14-26. ttt ! "`r 1Y Co <br /> � � ] <br />
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