88-50 - Laserfiche WebLink

Home Browse Search

- r a APPLICATION FOR PERMIT ? SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) 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 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 Local Health District. 49$0 East Woodbridge Rd Lodi 20acres Job Address 11 City Lot Size _ PM Marvin Mayer same 369-0577 Owner's Name Address Phone Clark Well 2024 East Charter 3715b0 462 7676 Contractor Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT IN DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca pia. of Well Excavation r} Dia. of Well Casing 12 4" I C3 Domestic/Private M Gravel Pack ❑ Tracy Type of Casing Steel Specifications # 8 f'l Public ❑ Other 171 Delta Depth of Grout Seal ...23-7 Type of Grout 9sack _ * Irrigation Approx, Depth I 1 Eastern Surface Seal Installed by Other Repair Work Done ❑ Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material Itop 501 1�I Depth Filler Material (Below 50') Cr TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR)ADDITION 1.1 DESTRUCTION I I lNo septic system permitted if public sewer is, I available within 200 feet.) Installation will serve: Residence_ Commercial Other r Number of living units: Number of bedrooms � Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG, TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line J` LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I 1 Depth Size Number SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and'that the work will be done in accordance with San Joaquin county ordinances, state taws, and 5 rules and regulations of the San Joaquin Local Health District; l 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 j employ any person in such manner as to become subiect to workman's compensation taws of California."Contractor's hiring or sub-contracting signature certifies the followi "I certify,tf"t i. the performance of the work for which this permit is issued,t shalt employ persons subject to workman' compensa- tion laws of qaf rnia." , f The applic; ustt I F r ui ina coons. Complete drawing on re j� Vit,y �/ ��°�:-- �,__,.(.,�• Signed F Title r Date: FOR DEPARTMENT USE ONLY Application Accepted by __ , E•w'�/�f/� �,(�� _ Date , Area TI Pit or Grout Inspection by... �- / f —Bate '� Final Inspection by Date �. Additional Commenter 0 Stlt ;466 b7$1 ❑ Lodi '3&9-3621 O Manteca 823-7104 Q Tracy 835-6385 ; Applicant Return.el)copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 rEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED 8Y DATE PER,MIT'NO. ,. .r. +,EiREV.rir+5i �t `'� 0 _r s