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88-839
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4200/4300 - Liquid Waste/Water Well Permits
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88-839
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Last modified
12/17/2019 10:06:10 PM
Creation date
12/5/2017 7:26:26 AM
Metadata
Fields
Template:
EHD - Public
ProgramCode
4200/4300 - Liquid Waste/Water Well Permits
RECORD_ID
88-839
PE
4366
STREET_NUMBER
12899
STREET_NAME
ATKINSON
STREET_TYPE
RD
City
LODI
SITE_LOCATION
12899 ATKINSON RD LODI
RECEIVED_DATE
04/07/1988
P_LOCATION
TED HAGLER
Supplemental fields
FilePath
\MIGRATIONS\A\ATKINSON\12899\88-839.PDF
QuestysFileName
88-839
QuestysRecordID
1649317
QuestysRecordType
12
Tags
EHD - Public
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APPLICATION FOR PERMIT j(J.00 <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> ( 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> L�'�UTelephone (209) 466-6781 <br /> PERMIT EXPIRES T 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 Addressrr►X 5©A. City �dC� Lot Size PM <br /> Owner's Name LL L V Q G 1<°I. Address ' C? �-.� 7 Phone ' <br /> Contractor t10,)1Je_%J Address R b ,A0 4Y e�(��G(License No.a99 Phone 26 9--;Z� r <br /> TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ,V;-� SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK l a Q r SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION - 410 AGRICULTURE WELL OTHER WELL&&_A_° PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS r <br /> ❑ Industrial M Open Bottom ❑ Manteca Dia. of Well Excavation_143-L Dia. of Well Casing <br /> ADomestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing '_'"' "d. Specifications <br /> ('1 Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout _CCL e_A _ <br /> I I Irrigation ---Approx. Depth I I Eastern Surface Seal Installed by A r. _ <br /> Repair Work Done ❑ Type of Pump S 4.) H.P.' a 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 11 REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is <br /> available within 200 feet.) S <br /> Installation will serve: Residence_ Commercial_ Other Q <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 Ll 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 applicant m t :all for all required inspections. Complete drawing on reverse side. <br /> Signed X 4 A-4 Title:__ & .S <br /> Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date a O Z Area v <br /> Pit or Grout Inspection by Date / Final Inspection by Date <br /> I ff 7�" <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Mantec 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 INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY (�^7DATE PERMIT NO. <br /> + EH 13-241REV.1/95) IOS O r —93 t, <br /> 8 <br /> EH 14-26 "��" Y <br />
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