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88-1073
EnvironmentalHealth
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4200/4300 - Liquid Waste/Water Well Permits
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88-1073
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Last modified
11/28/2019 10:06:42 PM
Creation date
12/4/2017 10:02:11 PM
Metadata
Fields
Template:
EHD - Public
ProgramCode
4200/4300 - Liquid Waste/Water Well Permits
RECORD_ID
88-1073
STREET_NUMBER
15777
Direction
S
STREET_NAME
DERBY
STREET_TYPE
LN
City
LATHROP
SITE_LOCATION
15777 S DERBY LN
RECEIVED_DATE
05/02/1988
P_LOCATION
PORFI VIGIL
Supplemental fields
FilePath
\MIGRATIONS\D\DERBY\15777\88-1073.PDF
QuestysFileName
88-1073
QuestysRecordID
1714813
QuestysRecordType
12
Tags
EHD - Public
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APPLICATION FOR PERMIT .. <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT L, <br /> . <br /> 1601 E. HAZE.T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 No W <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED �,L • � �,,� <br /> (Complete in Triplicate) �r/' <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 welllpump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> Job Address ' J ! / f City Lot Size_1001 ' ID� PM <br /> Owner's Name r , Address Phone ��u 5 6 <br /> Contractor OWt74eers Address License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Y _ <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 /> ❑ Industrial' ❑ Open Bottom ❑ Manteca Dia. of Wel! Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> ❑ Public Cl Other F] Delta Depth of Grout Seal Type of Grout - ,r <br /> I Irrigation --Approx. Depth I I Eastern Surface Seal Installed by �!\1 <br /> Repair WorkDone ❑ Type of Pump " H:P - ff�---—� State Work Done <br /> Well Destruction EI Well Diameter !�SeaIirig+Mat@jaI Itop 50'1 <br /> I - Depth . F$Ier,Mdt.ia14Below 50'1 <br /> TYPE-OF SEPTIC WORK: NEW INSTALLATION I] REPAIR/ADDITION [ I DESTRUCTION (No septic system permitted if public sewer is <br /> t i available within 200=feet.) <br /> Installation will serve: Residence Commercial Other <br /> Number of living units: __L_ Number/of bedrooms + <br /> I Character of soil to a depth of <br /> of 3 feet: i Water table depth <br /> SEPTIC TANK' Ad' Type/Mfg t Capacity 1 No. Compartments <br /> ` PKG:•TREATMENT PLT. 171 - j _ Method of Disposal <br /> n # s Distance to nearest: Well Foundation Property Line <br /> 4 � I <br /> i <br /> l LEACHING LINE ❑ No. 11 Length of lines Total length/.size <br /> t FILTER Bt_D ❑ Distance to nearest: Well Foundation Property Line y. <br /> SEEPAGE PITS I I Depth Size _ Number <br /> SUMPS L71 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 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 /> i employ any person in such manner as to become subject to workman's compensation laws of California."Contractors 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 Galifornia." <br /> l The applicantrriust call for all required inspections. Complete drawing on reverse side. <br /> 'Signed X - Title: W hem _ Date: <br /> FOR DEPARTMENT USE ONLY,-' �..-� y r - <br /> lApplication Accepted by 4 date z��� Area 13 <br /> Pit or Grout Inspection by t s Date ,Z Final Inspectibr.by Date <br /> iAdditional Comments: <br /> 1 ❑ Stk 466-6781 ❑ Lodi 3621 ❑ Manteca a23-7104 ❑ Tracy 835-6385 ..r Y_ <br /> Applicant- Return all copies to:-Environmen l Health Permit/Services 1601.E.-•Hazalton Ave., P.O. Box 2009, Stk., CA 95201 `(7J, <br /> •- <br /> FEE AMOUNTDUE AMOUNT REMITTED I CKCASH RECEIVED BY DATE PERMI7'NO. <br /> INFO <br /> + EH 13-241REV.t/1151 ��.� , 0 <br /> EH-14-28 <br />
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