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88-2644
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4200/4300 - Liquid Waste/Water Well Permits
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88-2644
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Entry Properties
Last modified
12/8/2019 10:46:06 PM
Creation date
12/4/2017 6:23:29 PM
Metadata
Fields
Template:
EHD - Public
ProgramCode
4200/4300 - Liquid Waste/Water Well Permits
RECORD_ID
88-2644
STREET_NUMBER
1918
Direction
S
STREET_NAME
CHURCH
STREET_TYPE
ST
City
LODI
SITE_LOCATION
1918 S CHURCH ST
RECEIVED_DATE
10/03/1988
P_LOCATION
GEWEKE PROPERTIES
Supplemental fields
FilePath
\MIGRATIONS\C\CHURCH\1918\88-2644.PDF
QuestysFileName
88-2644
QuestysRecordID
1691240
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 TYEAR 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 />Job Address i r r n 44 -�! . _ ` ...,r <br />i <br />Owner's Name P/1w Address �_(L= �� C�^-'� PhoneS3 K:: ICO <br />i <br />Contractor <br />Address License No,r'6 3 7 3 Phone /' F6 <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 />171 Public ❑ Other Cl Delta Depth of Grout Seal Type of Grout <br />I I Irrigation—_Approx. Depth I I Eastern Surface Seal'installed by <br />Repair Work Done ❑ Type of Pump H. P. State Work Done <br />Well Destruction Well Diameter Sealing -- Sealing Material Itop 50') <br />Depth 11Z____ Filler Material (Below 50') Il ! f <br />TYPE OF SEPTIC WORK: NEW INSTALLATION l 1 REPAIWADDITION l I DESTRUCTION I I INo septic system permitted if public sewer is <br />available within 200.feet.i <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 (_l Distance to nearest: Well Foundation Property Line <br />DISPOSAL PONDS Ll <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 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 st c I for all req�red inspecti S. Complete drawing on reverse side. <br />Signed X _Title: Date: / © 0 J <br />�p OR DEPARTMENT USE ONLY E+ �y I <br />Application Accepted by _�xo["axA Nlst ��.�luC w. __,_ Date �^TA5 Area <br />Pit or Grout Inspection by --- Date Final Inspection by /" s ' Date/P- - 9 9 <br />Additional Comments: _ / -- <br />❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ 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 />♦. EH 13-24 IREV. i i m s <br />EH 14-28 <br />FEE AMOUNT DUE <br />INFO <br />AMOUNT REMITTED <br />CA H <br />RECEIVED BY <br />DATE PERMIT NO. <br />eg 35,o -7c <br />0 <br />
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