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87-3797
EnvironmentalHealth
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4200/4300 - Liquid Waste/Water Well Permits
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87-3797
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Last modified
11/20/2019 10:05:58 PM
Creation date
12/4/2017 4:07:53 PM
Metadata
Fields
Template:
EHD - Public
ProgramCode
4200/4300 - Liquid Waste/Water Well Permits
RECORD_ID
87-3797
PE
4221
STREET_NUMBER
16039
STREET_NAME
CAMBRIDGE
STREET_TYPE
DR
City
LATHROP
SITE_LOCATION
16039 CAMBRIDGE DR
RECEIVED_DATE
10/15/1987
P_LOCATION
RAMON F RIVAS
Supplemental fields
FilePath
\MIGRATIONS\C\CAMBRIDGE\16039\87-3797.PDF
QuestysFileName
87-3797
QuestysRecordID
1676732
QuestysRecordType
12
Tags
EHD - Public
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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT f <br /> I 1601 E. HAZELTON AVE., STOCKTON, CA L� <br /> \ Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1'YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> I <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 /> Job Address Uj Cit ` " Lot Size — PM <br /> Owner's Name AddressPhon <br /> Zt� <br /> Contractor J ` r Address License No. Phone <br /> TYPE OF WELL/PUMP:, NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <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 M <br /> Ll Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications \ <br /> 1" Public P Other ❑ Delta Depth of Grout Seal Type of Grout _. <br /> I I I Irrigation —.-Approx. Depth l I Eastern Surface Seal Installed by Q <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material atop 501 <br /> Depth Filler Material Melow 50'1 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I DESTRUCTION (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> �. Installation will serve: Residence - Commercial _— Other <br /> Number of living units: Number of bedrooms <br /> J <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. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> + FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS i I Depth Size Number <br /> SUMPS L-I Distance to nearest: Welt—.-Foundation.— Property Line <br /> DISPOSAL PONDS ❑ <br /> 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 this permit is issued, I shall not <br /> employ any rson in such manner as to become subject to workman's compensation laws of California." Contractor's hiring-or sub-contracting signature <br /> certifies the lowing: "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 /> i <br /> tion lawstAccepted <br /> The applo II uired inspections. Complete drawing on reverse side. ll <br /> ` Signed X Title: �w Date: <br /> ZV'0RI DEPARTMENT USE ONLY <br /> ApplicatiDate � Are, X, ly <br /> Pit or GrDate ^ Final.lnspecti Date <br /> Additional Comments: <br /> + ❑ Stk 466-6781 ❑ Lodi 369-361 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <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 CASH RECEIVED BY DATE PERMIT-NO. <br /> INFO <br /> Q� <br /> + EH 13-241REV,7/H 5) 7—IN <br /> r -EH 14-26 <br />
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