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90-1552
EnvironmentalHealth
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NORTH RIPON
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4200/4300 - Liquid Waste/Water Well Permits
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90-1552
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Last modified
1/28/2020 10:12:26 PM
Creation date
12/3/2017 6:15:28 AM
Metadata
Fields
Template:
EHD - Public
ProgramCode
4200/4300 - Liquid Waste/Water Well Permits
RECORD_ID
90-1552
STREET_NUMBER
21919
Direction
S
STREET_NAME
NORTH RIPON
STREET_TYPE
RD
City
RIPON
SITE_LOCATION
21919 S NORTH RIPON RD
RECEIVED_DATE
06/21/1990
P_LOCATION
ED SHARP
Supplemental fields
FilePath
\MIGRATIONS\N\NORTH RIPON\21919\90-1552.PDF
QuestysFileName
90-1552
QuestysRecordID
1872021
QuestysRecordType
12
Tags
EHD - Public
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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE i ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> ?: PERMIT EXPIRES TYEAR 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. <br /> / I <br /> Job Address ! r i a ' City � 'PQA/ Lot Size PM <br /> .-� �1 � - <br /> Owner's Name G S Address cf-c C 0017 S, l f Phone <br /> D� <br /> Contractor r U Address 1 7N• License N 0 PhonetJ� <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPL) CEMENT\❑'J*q, J ADESTRUCTION 0 j <br /> SYSTEM REPAIR El <br /> OTHER ❑ <br /> PUMP INSTALLATION <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. POOP. LINE <br /> FOUNDATION, AGRICULTURE-WELL-,- —OTHER WELL- P_ITS�ISUMPS <br /> INTENDED USE TYPE OF-WELLTPROBtEM.AREA CONSTRUCTION SPECIFICATIONS v J <br /> .` . <br /> ❑ Industrial ❑ Open Bottom O Manteca' Dia. of Well Excavation Dia. of Well Casing;j <br /> 7`11 <br /> �omestic/Private ❑ Gravel Pack ❑ Tracy Type ai Casing Specifications f <br /> F`7 Public_ l,_O.ther I Fl Delta Depth of Grout Seal Type of Gfout <br /> I Irrigation —"Approx. Depth I 1Eastern�urface Seal Installed by I k - <br /> Repair Work Done Type of Pump H.P. State Work Done 1 <br /> Well Destruction El WL-11 Diameter Sealing Material (top 501 <br /> Depth Filler Material (Below 501 f <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 1-i REPAIR/ADDITION I I DESTRUCTION { I (No septic system permitted if public sewer is r <br /> k ^. e A available within 200 feet€I 4 <br /> Installation will serve: Residence_ -Commer6al Other , <br /> Number,,ofAivingtiun tris: '��Number df bedrooms,= -y t A <br /> Character,of soil to-a depth of 3 feetr" Water table depth., <br /> C. s Sa\1 , .' ' t <br /> 5EPTEC TANK O-. Type/Mfg -. <br /> Capacity No. Compartments f <br /> .� Method of Disposal <br /> PKG. TREATMENT PLT.'O..%1y 4�` t..� >� T� <br /> Distance to nearest: Well Foundation Property Line ' <br /> t � <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED El Distance to nearest: Well Foundation Property Line r <br /> SEEPAGE PITS l I Depth Size Number— <br /> _SUMPS= — L� Distance to nearest:' Well nFoundation - 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 thisyefmit 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 compenssa <br /> tion laws of California." <br /> The applicant s calt f all fe d in ctiorrs7�-Cornplete drawing on reVerse-side.N 4 <br /> Signed X Title: [/ Date: <br /> t <br /> FOR DEPARTMENT USE ONLY ) <br /> Application Accepted by Date a Area <br /> Pit or Grout Inspection by Data `CJI Final Inspection by Date— <br /> Additional Comments: <br /> LJ Stk 466-6781 ❑ Lodi 369-3621 LI Manteca 823-7104 ❑ Tracy 635-6365 <br /> Applicant - Return all copies to: EnviroAmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> f <br /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. <br /> INFO y �^ ,�,- <br /> a EH 13-24(REV.1/95) S �"�� v �Q / (O /Z-l- �t] f o -f5S <br /> I EH 14-2e <br />
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