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88-2601
EnvironmentalHealth
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DURHAM FERRY
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4200/4300 - Liquid Waste/Water Well Permits
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88-2601
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Last modified
12/7/2019 10:57:13 PM
Creation date
12/4/2017 10:47:00 PM
Metadata
Fields
Template:
EHD - Public
ProgramCode
4200/4300 - Liquid Waste/Water Well Permits
RECORD_ID
88-2601
STREET_NUMBER
4876
Direction
W
STREET_NAME
DURHAM FERRY
STREET_TYPE
RD
City
TRACY
SITE_LOCATION
4876 W DURHAM FERRY RD
RECEIVED_DATE
09/30/1988
P_LOCATION
RAY TARGOWSKI CONT
Supplemental fields
FilePath
\MIGRATIONS\D\DURHAM FERRY\4876\88-2601.PDF
QuestysFileName
88-2601
QuestysRecordID
1719223
QuestysRecordType
12
Tags
EHD - Public
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a <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <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.r <br /> Job Address <br /> 4850 W . DURHAM FERRY RD . City TRACY Lot Size PM <br /> Owner's Name Ray Targowski Const. Address 27743 S_ Corr_a 1 Hol 1 ow Rcl Phone835-2786 <br /> Contractor Hennings Rrnr,. Dri IlAddress IS25 PPlandale Ave_ License No. 2ACIR13 Phone <br /> TYPE OF WELL/PUMP: NEW WELL( WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK 8 fl I SEWER LINES 101 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 fi 11 <br /> LX Domestic/Private M Gravel Pack I Tracy Type of Casing 1 6 0 g a PUC Specifications <br /> ❑ Public CI Other ❑ Delta Depth of Grout Seal 100 1 Type of Grout R P n t rm.i-t P_. C <br /> I I Irrigation _..Approx. Depth I i Eastern Surface Seal Installed by � H E Al N IN G C B R C _ (� <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done _ <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION 1 l DESTRUCTION I i (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 feel: 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: Welt f=oundation Property Line <br /> SEEPAGE PITS l I Depth Size _ Number <br /> SUMPS ❑ 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 V <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 <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. Complete drgvving on reverse side. <br /> SignedX Title: � '� Date: <br /> FOR DEPARTMENT USE ONLY �] <br /> gg <br /> Application Accepted by p Date ` 1""4 Area ` <br /> Pit orrout pection by,,,-- a <br /> Dat��r rU Final Inspection by Date <br /> Additional Comments: "/() /I�//l,, _ <br /> ❑ Stk 466-6781 ❑ L�1 ❑ 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 INFO AMOUNT DUE AMOUNT REMITTED CK(1-14 CASH RECEIVED BY DATE pPERMiT'NO. <br /> i.EH 14-21fREV.tin51 ��j+ /'� / l� ��� /1-`� f <br /> Eli 11-2a P' �! V /r <br />
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