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3500 - Local Oversight Program
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PR0545276
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Last modified
2/3/2020 8:42:03 AM
Creation date
1/31/2020 4:48:16 PM
Metadata
Fields
Template:
EHD - Public
ProgramCode
3500 - Local Oversight Program
File Section
FIELD DOCUMENTS
RECORD_ID
PR0545276
PE
3528
FACILITY_ID
FA0004997
FACILITY_NAME
PLUG CONNECTION LLC
STREET_NUMBER
5400
Direction
E
STREET_NAME
HARNEY
STREET_TYPE
LN
City
LODI
Zip
95240
APN
06106019
CURRENT_STATUS
02
SITE_LOCATION
5400 E HARNEY LN
P_LOCATION
99
P_DISTRICT
004
QC Status
Approved
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EHD - Public
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APPLICATION FOR PERMI,` j <br /> 1 <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICfiS <br /> ENVIRONMENTAL HEALTH DIVISION VEL <br /> 1601 E. HAZELTON AVE. , PHONE (209)468-3420 <br /> P O BOR 2009, STOCKTON. CA 95 <br /> D „� i3J <br /> gMWIT FIRES 1 YEAR FROM DATE <br /> (Complete in Triplicate) ^;pNMeNAL H ALT: <br /> Application is hereby mede,to San Joaquin County for a permit to construct and/or install the vork herein'decc`ribM.'"This <br /> application is made in compliance vith San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> i. Joaquin County Public Health Services. - . <br /> s•Y I 10 <br /> Job Address 5400 E*.S+ H-Ae.,1aM^ City LoU _ Lot Size/Acreage <br /> Color Spot I✓1C. Address 5400 Ea k {}ta+ Lie Phone 209 333-oZ <br /> Owner's Name gaxr 1 <br /> ContractorW EST&A Address P.O. lux 1664 W. SAC,CPucense No.!-5-57-116 Phone 916 3"13' 10 <br /> TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION O Out of Service Nell ❑ <br /> PUMP INSTALLATION ❑ SYSTEM/REPAIR ❑ OTHER ❑ Monitoring Melly <br /> DISTANCE TO NEAREST: SEPTIC TANK 200 . SEWER LINES J /A_ <br /> DISPOSAL FLD. A PROP. LINE La�Q�/LF'-f. <br /> j" FOUNDATION OD AGRICULTURE WELL I S o'R,OTHER WELL PITS/SUMPS <br /> + INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS E4 <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation LO Dia. of Well Casing <br /> (71 Domestic/Private Gravel Pack ❑ Tracy Type of Casing 9 I. S&6• ho PVC Specifications <br /> 1'I Public 1:1 Other f1 Delta Depth of Grout Seal 38-f{ — 5v4-1t Type of Grout a'k <br /> I I trri0ation —Approxi Depth 11 Eastern Sud EeSeal Installed by �I re-wr•^�C �!. L -- SL+''+" ' <br /> Repair Work Done v Type of Pump PIA H.P. State Work Oona_ <br /> Well Destruction O Well Diameter 2r Sealing M� rial & Depth - B 4 �.�^^ ^' <br /> Depth x 60 {, Filler Material & Depth Grr»e 1 �r-Jc UO S Mo✓rf'ei1l $w...Q O.(' <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION 1 I DESTRUCTION 111No septic system permitted it public sewer is <br /> available within 200 last.) <br /> tnsmllatione: Residence— Commercial_ Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 W ale depth <br /> SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT.❑ Method of Disposal <br /> Distance to nearest: Well Found Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance t rest: Well Foundation Property Line <br /> 1 SEEPAGE PITS I Depth Size Number <br /> SUMPS ll Distance to nearest: Well Foundation Property Line <br /> DISP L PONDS ❑ <br /> I hereby cenify that I have prepared this application and that the work will bodone 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:awe of California."Contractor's hiring or subcontracting signature <br /> certifies the following:"I certify that in the perform ce of the work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> rion Ism of Clifornial' _ <br /> The applicant t(sl�rlewI "r /uir inspo'CiArA gii tt drawing on reverse side. 7 <br /> Sigr �K /'tl.-'I� Y=�✓V�v,-:/!/.L h-Gf � /Jf/✓I/uT////7 CTitle: 1 !!/1 DJIe: <br /> -gCEYwF¢11 DEPARTMENT USE ONLY <br /> Application Accepted by t- /JK�K. dyCL�i Date Area <br /> �. Pit or Grout Inspection by Date Final <br /> 'InJsppA/ctio,(n�byd-=�!�'L /�Da[s <br /> Additional Comments: 1""""'� W) (TnON� L1_ (f+ ��V — �l io ` <br /> �. Applicant - Return all copies to: Joaquin County Public Health <br /> Services, Environsental Health Permit/Services <br /> 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK 11 EIVED BY DATE PERMIT NO. <br /> NFO CASH <br /> E <br /> 113-24(REV vxm goo° �g� 1090 3 92 4a- us <br />
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