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88-1068
EnvironmentalHealth
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DURHAM FERRY
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4491
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4200/4300 - Liquid Waste/Water Well Permits
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88-1068
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Last modified
11/28/2019 10:07:36 PM
Creation date
12/4/2017 10:46:07 PM
Metadata
Fields
Template:
EHD - Public
ProgramCode
4200/4300 - Liquid Waste/Water Well Permits
RECORD_ID
88-1068
STREET_NUMBER
4491
Direction
W
STREET_NAME
DURHAM FERRY
City
TRACY
SITE_LOCATION
4491 W DURHAM FERRY
RECEIVED_DATE
04/26/1988
P_LOCATION
STELLA RUIZ
Supplemental fields
FilePath
\MIGRATIONS\D\DURHAM FERRY\4491\88-1068.PDF
QuestysFileName
88-1068
QuestysRecordID
1719164
QuestysRecordType
12
Tags
EHD - Public
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APPLICATION FOR PERMIT _ <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT s�' <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA •. " <br /> Telephone (209) 466-67$1 APF? 2 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) )EIV�IRG�iL;v7RL HLA 7 <br /> ER <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein desc�Ak5�BM �it�0is <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 Sa �oaquin <br /> Local Health District. <br /> Job Address 0rhCLM �c�1�'_� City _VV–aQ Lot Size PM <br /> rt, iC�/Phone 3��Zrjs <br /> Owner's Name Address II <br /> Contractor C Address SS fi .License No. 2g Q Q 15 Phone545' 1185 <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 <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack Tracy Type of Casing Specifications <br /> {") Public Cl Other rl Delta Depth of Grout Seal Type of Grout <br /> i I Irrigation _.Approx. Depth l I Eastern Surface Seal Installed by _ <br /> Repair Work Done ❑ Type of Pump H.P. © State Work Done / <br /> Weil Destruction )� Well Diameter �}� '1 <br /> Sealing Material (top 50 <br /> ) <br /> Depth bb Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION-i I REPAIR/ADDITION I ) DESTRUCTION 1 1 (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 /> 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 LI Distance to nearest: Well Foundation Property Line rrr <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 /> employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signat <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 must call for all required inspections Co I to drawing on reverse side. 11II l �7 p <br /> Signed Xtle "' Date: <br /> OR DEPARtMENT USE ONLY <br /> Application Accepted by Date X 2 Aria <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 623-7104 ❑ 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 RECEIVED BY DATE PERMIT ND. <br /> INFO <br /> ♦ EH 13-241REV.tiK51 <br /> EH 14-2e c <br />
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