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84-733
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4200/4300 - Liquid Waste/Water Well Permits
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84-733
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Last modified
8/18/2019 10:22:17 PM
Creation date
12/5/2017 6:57:32 AM
Metadata
Fields
Template:
EHD - Public
ProgramCode
4200/4300 - Liquid Waste/Water Well Permits
RECORD_ID
84-733
PE
4382
STREET_NUMBER
3861
Direction
E
STREET_NAME
ARMSTRONG
STREET_TYPE
RD
City
LODI
SITE_LOCATION
3861 E ARMSTRONG RD LODI
RECEIVED_DATE
06/13/1984
P_LOCATION
JOHN KESZLER JR
Supplemental fields
FilePath
\MIGRATIONS\A\ARMSTRONG\3861\84-733.PDF
QuestysFileName
84-733
QuestysRecordID
1646486
QuestysRecordType
12
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EHD - Public
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APPLICATION FOR PERMIT <br /> IBJ SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON 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 /> ��f�r <br /> Job Address City tea"`" Lot Size PM <br /> Owner's Name YAddress U bJ or. (�L/�1lhGff�-r �67�' Phone —31i <br /> Contractor's Name ��y 4r1C' !– cense Nql `� 7 Phone3(. _3,C <br /> TYPE OF WELL/PUMP: NEW WELL❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR li�o 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 /> C'Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation ---Approx. Dep ❑ Eastern Sprface Seal Installed by <br /> Repair Work Done 1;4" Type of Pump H.P. Y State Work Don <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> Depth Filler Material (Below 501 W <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is 00 <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 m <br /> SEPTIC TANK ❑ Type/Mfg Capacity 'No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> 7 <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line J <br /> SEEPAGE PITS ❑ Depth Size Number G <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> 1 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 c2n� it inspections Complete drawing on arse side. <br /> �j� <br /> Signed le: �y` Date: <br /> FODE ARTMENT USE ONLY <br /> Application Accepted by Date r Area <br /> Pit or Grout Inspection by Date_ Final Inspection bZ��// �� Date ZZ�J <br /> Additional Comments: 1 <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 <br /> INFO AMOUNT DUE AMOUNT REMITTED CCK RECEIVED BY DATE PERMIT`N0. <br /> +EH 13-24(REV.10/831 S <br /> EH 1428 /\-i' O O' ,> �0/1 e �1 -9 Li-7 A3 <br />
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