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82-721
EnvironmentalHealth
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EHD Program Facility Records by Street Name
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99 (STATE ROUTE 99)
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20666
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4200/4300 - Liquid Waste/Water Well Permits
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82-721
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Last modified
11/19/2024 1:53:40 PM
Creation date
12/3/2017 4:49:59 AM
Metadata
Fields
Template:
EHD - Public
ProgramCode
4200/4300 - Liquid Waste/Water Well Permits
RECORD_ID
82-721
STREET_NUMBER
20666
Direction
N
STREET_NAME
STATE ROUTE 99
SITE_LOCATION
20666 N HWY 99
RECEIVED_DATE
12/13/1982
P_LOCATION
PERSEPHONE CAPIS
Supplemental fields
FilePath
\MIGRATIONS\N\99 (HWY99)\20666\82-721.PDF
QuestysFileName
82-721
QuestysRecordID
1879582
QuestysRecordType
12
Tags
EHD - Public
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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT PERMIT NO. U� 7 <br /> 1601 E. HAZELTON AVE., STOCKTON, CA 1 ,Y. <br /> ` Telephone (209) 466-6781 DATE ISSUED toy/3 <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 <br /> described. This application is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump <br /> y and the Rules and Regulations of the San Joaquin Local Health District. <br /> t Job Address d Subdivision Name <br /> Address IV Phone (y <br /> Owner's Name e _ Phone 1-4 I <br /> Contractor's Name License No. ,��y)) ;1 <br /> TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ 7' I <br /> PUMP INSTALLATION F-1SYSTEMSYSTEM REPAIR ❑ ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK �_^� SEWER LINES DISPOSAL FLU. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL P1T5/SUMPS <br /> INTENDED USE k TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Industrial f❑Open Bottom ❑Manteca Dia. of Well Excavation <br /> ❑ Domestic/Private F-1Gravel Pack ❑ Tracy <br /> Dia, of Well Casing <br /> Public []Other . ❑Delta Type of..Casing <br /> ❑ Irrigation Approx. ❑Eastern 4 = Specifications <br /> ❑Cathodic Protection Depth w <br /> Depth of Grout Seal <br /> (Ll Geophysical Type of Grout <br /> ❑Other ` Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done r <br /> Well Destruction L_f Well Diameter Sealing Material (top 501) <br /> Depth Filler Material (Below 50') <br /> E TYPE OF SEPTIC WORK: 'NEW`INSTALLATION REPAIR/ApDITION` ❑^(No�se}itic tank seepage pit permitted if public sewer is <br /> I . I available within 200 feet.) <br /> Installation will serve: Residence� Commercial _ Other �!O � � O� h� Aj►� <br /> Number of living units: Number of bedrooms Lot size�0 Y i T <br /> Character of soil to a depth of 3 feet-.. 1�r�'1 n M Water table depth <br /> SEPTIC TANK Type/Mfg Capacity o r No. Compartments <br /> PKG. TREATMENT PLT..❑ Type/Mfg Capacity T-e iMethod of Disposal <br /> Distance to nearest: Well. =h Foundation - Property.Line <br /> LEACHING LINE No. & Length of ]fines 8 µ-_,Total length/size <br /> S <br /> FILTER BED- ❑ Distance to nearest: Well Foundation. X Property.Line <br /> SEEPAGE PITS ❑ Depth Size (umber <br /> SUMPS ❑ 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 /> f Home owner or licensed agent's signature certifies the following: "I certify that in-the performance of'the work for which this <br /> n such'-manner.as to become subjectto workmant compensation laws of California." <br /> permit is issued, I shall not employ any person i <br /> Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work for which <br /> this permit is issued, I shall employ persons subject to workman's compensation;laws of4�Californ __ <br /> The ap icant ust call for all required inspections. Complete drawing on reverse side. <br /> Sign X Title: r Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Berea 1 ❑ Stk 466-6781 <br /> t C$vAk # Lodi 369-3621 <br /> Additional Comments: <br /> Pit or Grout Inspection by e ❑ Manteca 823-7104 <br /> Final Inspection by Date ❑ Tracy 835-6385 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 20D9, Stk., CA 95201 <br /> FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. <br /> INFO c J_^ <br /> cH 13-24 REV. 10/82 � { 16/82 500 <br /> f 14-26 <br />
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