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88-2986
EnvironmentalHealth
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DURHAM FERRY
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4200/4300 - Liquid Waste/Water Well Permits
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88-2986
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Last modified
12/9/2019 10:39:51 PM
Creation date
12/4/2017 10:48:11 PM
Metadata
Fields
Template:
EHD - Public
ProgramCode
4200/4300 - Liquid Waste/Water Well Permits
RECORD_ID
88-2986
STREET_NUMBER
5101
STREET_NAME
DURHAM FERRY
STREET_TYPE
RD
City
TRACY
SITE_LOCATION
5101 DURHAM FERRY RD
RECEIVED_DATE
10/15/1988
P_LOCATION
WILLIAM METZ
Supplemental fields
FilePath
\MIGRATIONS\D\DURHAM FERRY\5101\88-2986.PDF
QuestysFileName
88-2986
QuestysRecordID
1719301
QuestysRecordType
12
Tags
EHD - Public
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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. <br /> r-+ <br /> Job Address City Lot Size PM <br /> Owner's Name Address „ /�/ Phone Ive <br /> Contractor A res License No.�Phon -. <br /> TYPE OF WELL/PUMP: EW WELL WELL REPLACEMENT ❑ DESTRUCTION Q <br /> PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS O <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Ind ia1 ❑ Open Bottom �❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> C�"Domestic/Private ❑ Gravel Pack R-f,'acy Type of Casing Specifications <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> ID Irrigation ---Approx. DepY ❑ Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. ,2-. _ State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> Depth Filler Material {below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAtR/ADDITION ❑ DESTRUCTION ❑ INo 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 ❑ 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 <br /> employ any person in such manner as to become subject to workman's oompensation 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 f op all required inspections. Complete drawing on <br /> reverse side. /� �+� <br /> Signed Title: Date%l_' '/ d1 <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by r Date ? V Area <br /> Pit or Grout Inspection by Date Final Inspection by Date& <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-M <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, tk., CA 85201 <br /> FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY )DATE PERMIT NO. <br /> + EH13-24 4REV.1/a 51 113011 <br /> EH 14-29 cJ <br />
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