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88-532
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4200/4300 - Liquid Waste/Water Well Permits
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88-532
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Last modified
12/14/2019 10:10:28 PM
Creation date
12/3/2017 5:39:15 AM
Metadata
Fields
Template:
EHD - Public
ProgramCode
4200/4300 - Liquid Waste/Water Well Permits
RECORD_ID
88-532
STREET_NUMBER
3003
STREET_NAME
NAVY
STREET_TYPE
DR
City
STOCKTON
SITE_LOCATION
3003 NAVY DR
RECEIVED_DATE
03/11/1988
P_LOCATION
TESORO OIL
Supplemental fields
FilePath
\MIGRATIONS\N\NAVY\3003\88-532.PDF
QuestysFileName
88-532
QuestysRecordID
1867687
QuestysRecordType
12
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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 /> i <br /> PERMIT EXPIRES 1-YEAR FROM DATE ISSUED <br /> 6 (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. <br /> j � j k <br /> Job Address J004 I`' City Lot Size PM <br /> Owner's Name — [[TJ©�� _ Address Phone <br /> L'Pt .. <br /> Contractor VW Address `Y' `� l�VD2LA ST- License No, Fr�so2 Phone2Ft� 682"S bo <br /> TYPE OF WELLIPUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ` r 2 ~MW60_I�.� <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 <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> M Public F1 Other I ❑ Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation _.Approx.lbapth I i Eastern Surface Seal Installed by _ <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> Depth Filler Material (Below 501 Q <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION l I INo septic system permitted if public sewer is <br /> available within 200 feet.) Ly <br /> Installation will serve: Residence_i Commercial_ Other <br /> Number of living units: Number of bedrooms ; <br /> Character of soil to a depth of 3 feet:#t Water table depth <br /> SEPTIC TANK ❑ Type/Mfg... Capacity No. Compartments 1 <br /> PK G. TREATMENT PLT. ❑ = Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Lerigth of lines Total length/size <br /> FILTER BED ❑ Distance to'nearest: - Well— Foundation Property Line <br /> SEEPAGE PITS I I Depth i'1 <br /> p 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 ordinances, state laws, and { <br /> rules and regulations of the San Joaquirk Local Health Di§trict.. <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 call for ail required ' spections. Complete drawing on reverse side. <br /> 7 <br /> Signed X r r - r r Title: /ZO ,a`DL0r5 Cs C pate: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by ! d A __. _ Date `�" �J� Area <br /> Pit or Grout Inspection by Date 3A �Sl Final Inspection by Date I RC1 <br /> Additional Comments: <br /> ❑-Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca '823-7104 ❑ Tracy 835-6385 <br /> Applicant- Return all copies to: Environitiantal Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> 4 , <br /> FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT'NO. <br /> INFO24 <br /> G t\`t•�� G IS,EH 14 2e 1AEV.t i H 51 3��. d 16 v\ � L11 O� S__5 <br />
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