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SU0011920
Environmental Health - Public
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EHD Program Facility Records by Street Name
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GREENWOOD
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2600 - Land Use Program
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PA-1800183
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SU0011920
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Entry Properties
Last modified
12/13/2021 11:06:23 AM
Creation date
9/5/2019 10:51:02 AM
Metadata
Fields
Template:
EHD - Public
ProgramCode
2600 - Land Use Program
RECORD_ID
SU0011920
PE
2632
FACILITY_NAME
PA-1800183
STREET_NUMBER
34150
Direction
S
STREET_NAME
GREENWOOD
STREET_TYPE
RD
City
TRACY
Zip
95304-
APN
25525009
ENTERED_DATE
9/4/2018 12:00:00 AM
SITE_LOCATION
34150 S GREENWOOD RD
RECEIVED_DATE
12/28/2018 12:00:00 AM
P_LOCATION
99
P_DISTRICT
005
QC Status
Approved
Scanner
SJGOV\tsok
Supplemental fields
FilePath
\MIGRATIONS\G\GREENWOOD\34150\PA-1800183\SU0011920\APPL.PDF
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EHD - Public
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APPLICATION FOR PERMIT ell <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE i ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <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 described. This application is <br /> made in compliance with San Juaquin 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 /> Job Addref,/ W.4V /J� City Tr�1O Lot Size (,O/1cYz'r _ PM <br /> ss �,--- <br /> Owner's Name QC 7Tr'r �re��� -- Address Phone <br /> Contractor _ARr/So�✓ SOry Address SCR 9wC v^ ✓r., License No. //J�f`ry Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION 1-I <br /> PUMP INSTALLATION Ll SYSTEM REPAIR l7 OTHER ❑ <br /> DISTANCE TO NEARE- ST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> ----- -- ------ <br /> FOUNDATION AGRICULTURE WELL OTHER WELL_ PITS/SUMP <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> 171 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> 11 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> ('I Public I 1 Other 11 Delta Depth of Grout Seal ___ _ Type of Grout_..__ <br /> I I Irrigation __Approx. Depth I I Eastern Surface Seal Installed by---------- <br /> Repair <br /> y -- -----Repair Work Done [_7 Type of Pump H.P. — State Work Done ---------- <br /> Well Destruction I 1 Well Diameter Seating Material Itop 50'I --- --- ---- -- <br /> Depth Filler Material (Below 50') --- - <br /> TYPE OF SEPTIC WORK. NEW INSTALLATION I I REPAIR/ADDITION 1 DESTRUCTION I I (No septic system permitted it public sewer is <br /> available within 200 feet.) <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: '4Ler1A4 Water table depth <br /> SEPTIC TANK 1.1 Type/Mfg Capacity_ No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal _ <br /> Distance to nearest: Well /A OL z Foundation_ _._- Property Line <br /> LEACHING LINE I No. & Length of lines — Total length/size-------- <br /> FILTER <br /> ize _----_FILTER BEDS 6 IX Distance to nearest: Well 1,200' Foundation __._— Property Line So' <br /> SEEPAGE PITS I I Depth _...__ Size �x�X _._ Number _6 --..--- <br /> SUMPS L I Distance to nearest: Well _ Foundation Property Line <br /> _DISPOSAL PONDS 1 ) <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with Sart 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 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 /> lion laws of California.'' <br /> The applicant must call for all required inspections. Complete drawing <br /> Signed X— .l i _ Title: - - Date: S _�9 ------- <br /> �� y6R DEPARTMENT USE ONLY .�j � <br /> Application Accepted by __— Date Area <br /> Pit or Grout Inspection by Date Final Inspection by ' f''J Date <br /> Additional Comments: - <br /> :7 Stk 466-6781 C3Lodi 369-3621 ElManteca 1323-7104 ElTracy 835-&385 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT N0. <br /> � <br /> c <br /> EH 1324(REV i��ti INFO t7\73 r � c. _ <br /> EH 1 2E 6 L <br />
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