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SU0005756
Environmental Health - Public
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2600 - Land Use Program
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PA-0500745
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SU0005756
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Entry Properties
Last modified
11/19/2024 3:48:13 PM
Creation date
9/9/2019 10:25:59 AM
Metadata
Fields
Template:
EHD - Public
ProgramCode
2600 - Land Use Program
RECORD_ID
SU0005756
PE
2631
FACILITY_NAME
PA-0500745
STREET_NUMBER
5184
Direction
W
STREET_NAME
STATE ROUTE 12
City
LODI
APN
05516022
ENTERED_DATE
11/4/2005 12:00:00 AM
SITE_LOCATION
5184 W HWY 12
RECEIVED_DATE
11/4/2005 12:00:00 AM
P_LOCATION
99
P_DISTRICT
004
QC Status
Approved
Scanner
SJGOV\sballwahn
Supplemental fields
FilePath
\MIGRATIONS\T\HWY 12\5184\PA-0500745\SU0005756\PUB REC REL APPL.PDF
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EHD - Public
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APPLICATION FOR PERMIT y <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ' <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> (209) 468-3447 l <br /> I YEAR <br /> (Complete in Triplicate) <br /> Application is hereby made,to San Joaquin County for a permit to construct and/or instal] tgfik ereie <br /> ��9{{{ ns This <br /> application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and th 1 R f San <br /> Joaquin County Public Health Services. <br /> Job Address _ �� y Z-) 7,L /27`� / City ,Z OA 1 Lot Size/Acreage <br /> ^ ra u J` l A` Z A Phone Ca 335 11 <br /> �i-r �It��{ Address <br /> Owner's Name !�n <br /> Contractor_[� d �O��l,¢ (Rr __Address License No. 11 Tad Phone 06". <br /> TYPE OF WELL/PUNY: NEW WELL 0 WELL REPLACEMENT Cl DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION Cl SYSTEM REPAIR ❑ OTHER Mq nitoring Well <br /> C7 <br /> Srri 1 W t or <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 /> rial O Open Bottom O Manteca Dia. of Well Excavation Dia. of Well Casing <br /> 011".111tic/Private ❑ Gravel Pack L7 Tracy <br /> Type of Casing Specifications <br /> M Public 111 Other O Delta + Depth of Grout Seal 1tZ#4Type of Grout <br /> G IrtiUation _Approx. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done U Type of Pump H.P. State Work Done <br /> Well Destruction Ia -"Welt Diameter- Sealing Material i Depth _a- O I <br /> Depth L't Filler Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION D REPAIR/ADDITION 0 DESTRUCTION D (No septic system permitted if public sewer is <br /> available within 200 feet.} <br /> 7. <br /> Installation will serve: Residence— Commercial— Other <br /> Number of living units: Number of bedrooms k <br /> Character of soil to a depth of 3 feet: Water table depth <br /> r , <br /> SEPTIC TANK. 0 Type/Mfg ' Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ 1 Method of Disposal <br /> Distance to nearest: Well Foundation. Property Line <br /> LEACHING LINE C1 No. & Length of lines Total length/size <br /> FILTER BED n Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS l I Depth Sue Number <br /> SUMPS U Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS 0 <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 taws, and <br /> rules and regulations of the San Joaquin County l <br /> Home owner or licensed agent's signature cerlifies the following: "I cenify.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 taws of California." Contractors hiring or sub-contracting signature <br /> certifies the following: "I nify 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 Calif <br /> The applic must c f r uired inspections. Complete drawing on reverse side. <br /> n a <br /> Signed Title: Date: <br /> ZFODEPARTMENT USE ONLY j 2 <br /> Application Accepted by Date ^2--3124/ Area I�! <br /> Pit or Grout Inspection by Dated� / Final Inspection by Date <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 65201 <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED C 5H RECEIVEO By DATE, J !I ERMI7 NO. <br /> '• EM 7� ZmI11EY.rinSl � f `tea � UJ m r` ['/� {�-f CI�I�V2 <br />
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