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88-2134
EnvironmentalHealth
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4200/4300 - Liquid Waste/Water Well Permits
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88-2134
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Last modified
12/4/2019 10:13:23 PM
Creation date
12/4/2017 10:02:57 PM
Metadata
Fields
Template:
EHD - Public
ProgramCode
4200/4300 - Liquid Waste/Water Well Permits
RECORD_ID
88-2134
STREET_NUMBER
16032
STREET_NAME
DERBY
STREET_TYPE
LN
City
LATHROP
SITE_LOCATION
16032 DERBY LN
RECEIVED_DATE
08/19/1988
P_LOCATION
FRANK LOPEZ
Supplemental fields
FilePath
\MIGRATIONS\D\DERBY\16032\88-2134.PDF
QuestysFileName
88-2134
QuestysRecordID
1714910
QuestysRecordType
12
Tags
EHD - Public
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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT I <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA No <br /> Io� "` " <br /> 4 <br /> Telephone (209) 466-6781 'v / <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED � <br /> /�'�,�`- - <br /> (Complete in Triplicate) l/$ <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 /[/ `� 21 e T City ""a ft Lot Size PM <br /> Owner's Name fro,n a ��7�Z Address /w/o S Z .f/ a h k,l i Z1r1n P, Phone <br /> Contractor SA Address License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ i <br /> DISTANCE TO NEAREST: SEPTIC TANKv 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 + C1 Manteca Dia, of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> 1 1 Irrigation _..Approx. Depth I I Eastern Surface Seal Installed by _ <br /> Repair Work Done L1Type of Pump H.P, State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 t�\h <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATIO REPAIR/ADDITION i.l DESTRUCTION (No septic system permitted if public sewer is <br /> fflvailable within 200 feet.) <br /> Installation will serve: Residence X Commercial_ Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: 5�- 1�Cx,M�L- Water table depth g <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. El Method of Disposal <br /> Distance to nearest: Well Foundation Property-Line <br /> LEACHING LINE ❑ No. & Length of lines F Total length/size 1 <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS I i Depth Size Number <br /> SUMPS Ll Distance to nearest: Well"" Foundation Property Line <br /> DISPOSAL PONDS ❑ r <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 I <br /> rules and regulations of the San Joaquin Local Health Diltrict. E <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 F <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 California." <br /> The applicant m t call fo I req 'ed ins tions Com eta drawing on reverse side. �A <br /> Signed X e "" d Title: _ E)l )-s Date: / r <br /> 4 EP-ARTMENT USE ONLY <br /> Application Accepted by Date a- <br /> Pit or Grout Inspection by Date Final Inspection b Dat <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ LodIF369-3621 ❑ 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 /> INFEE F AMOUNT DUE AMOUNT REMITTED CKK_ 'RECEIVED BY DATE PEERMIT NO. <br /> ♦,EH53-24 1REV.1 i r15] OD <br /> EH 14-28 V J <br /> f <br />
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