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91-0562
Environmental Health - Public
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THORNTON
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4200/4300 - Liquid Waste/Water Well Permits
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91-0562
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Last modified
3/12/2020 12:13:31 PM
Creation date
12/2/2017 1:05:24 AM
Metadata
Fields
Template:
EHD - Public
ProgramCode
4200/4300 - Liquid Waste/Water Well Permits
RECORD_ID
91-0562
STREET_NUMBER
9009
STREET_NAME
THORNTON
STREET_TYPE
RD
City
STOCKTON
SITE_LOCATION
9009 THORNTON RD
RECEIVED_DATE
3/12/91
P_LOCATION
FREDRICK FREIBENG
Supplemental fields
FilePath
\MIGRATIONS\T\THORNTON\9009\91-0562.PDF
QuestysFileName
91-0562
QuestysRecordID
1946502
QuestysRecordType
12
Tags
EHD - Public
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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION l <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> (209) 468-3447 <br /> PERMIT MIRRE 1 YEAR PROM_ DATE ISSUSp <br /> (Complete in Triplicate) <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work herein described. This j <br /> application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San l <br /> Joaquin County Public Health Services. ]� <br /> Job Address d Q City ` Lot Size/Acreage <br /> i <br /> 0. Owner's Name � � `�'� ddress / if �-� Phone <br /> X Contractor Address F7r,5License No. g�q O Phone ff� <br /> TYPE OF WELLIPUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service We11 ❑ <br /> INSTALLATION ❑ SYSTEM REPAIR 0 OTHER ❑ oring Well C] <br /> DISTANCE TO NEAREST: SEPTIC T SEWER LINES DISPOSAL FLO. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL — OTHE PITS/SUMPS .r <br /> INTENDED USETYPE OF WELL PROBL EA CONSTRUC ECIFICATIONS <br /> tI Industrial ❑ Open Bottom ❑ Manteca Well Excavation Dia. of Well Casing ' <br /> U Domestic/Private ❑ Gravel Pack 0 Trac Type o sing Specifications <br /> M Public (I Other Oita Depth of Grout 1 Type of Grout <br /> 0 Irrigation epth 0 Eastern Surface Seal Installed b O <br /> Repair Work Done ype of Pump H.P. State Wor e <br /> Well Destruction ❑ Well Diameter Sealing Material i Depth <br /> _ Depth Filler Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION,0 REPAIRIADDITION LI DESTRUCTION lNo septic system permitted it public sewer is <br /> available within 200 feet.l <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 <br /> SEPTIC TANK. . ❑ Type/Mfg Capacity—. No. Compartments <br /> PKG. TREATMENT PLT. C1 Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED C.l Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS LI 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 County <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 t f It ed inspections. Complete drawing on re sr".Z.O_ . <br /> si , �j <br /> ,,),(Signed Title- ....>aDate: -- <br /> Fff DEPARTMENT USE ONLY l <br /> Application Accepted by Date�� L.__._ Area <br /> Pit or Grout Inspection by Date Final inspection by �-^�^�'� Data Yhk <br /> Additional Comments: — <br /> Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> 445 N SAN JOAQUIN, P 0 BOX 2009, STOCKTON, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED GK RECEIVED BY DATE PERMIT'NO, <br /> INFO rill <br /> (� <br /> r Ek t4- IREV,s/n 5I ..] 41 l I <br />
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