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88-781
EnvironmentalHealth
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ARMSTRONG
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1607
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4200/4300 - Liquid Waste/Water Well Permits
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88-781
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Last modified
12/16/2019 10:10:37 PM
Creation date
12/5/2017 6:53:48 AM
Metadata
Fields
Template:
EHD - Public
ProgramCode
4200/4300 - Liquid Waste/Water Well Permits
RECORD_ID
88-781
PE
4380
STREET_NUMBER
1607
STREET_NAME
ARMSTRONG
STREET_TYPE
RD
City
LODI
SITE_LOCATION
1607 ARMSTRONG RD LODI
RECEIVED_DATE
04/04/1988
P_LOCATION
DARRIGO BOO OF CALIFORNIA
Supplemental fields
FilePath
\MIGRATIONS\A\ARMSTRONG\1607\88-781.PDF
QuestysFileName
88-781
QuestysRecordID
1646699
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 /> Job Address 2doL2 &/o " City ! Lot Size PM <br /> Owner's Namef ►�( itc 6�. dry.o k i _Address 7 0�£��( !� ��.�1%4 1.�r Phone <br /> Contractor s -N 7A C Address e aZ�a r. L a License No. Phone, <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 ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> Irrigation ---Approx. Depth ®❑ Eastern Surface Seal Installed by <br /> Repair Work Done ;K Type of Pump J 3dI H.P. /4 State Work Don JZ2Zw- <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is 6 <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 /> Ci <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 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 applic call for all required pectin Compl drawing on reverse side. <br /> Signed Title: �`� Date: —5r1//V/Pa 'do <br /> �y� ,FO.R�DEPARTMENT USE ONLY <br /> Application Accepted by / 1 U �`'i' Date 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 835-6385 <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 CK RECEIVED BY DATE PERMIT NO. <br /> INFO CASH <br /> + EH 124(REV.t H 5) C <br /> EH 14-4-28 �VVJ<..� IN/9`0" T^-79 <br />
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