83-160 - Laserfiche WebLink

Home Browse Search

Note." Test well by City Of Lodi APPLICATION FOR PERMIT i SAN JOAQUIN LOCAL HEALTH DISTRI�7�s Return Permit t0 1601 E. HAZELTON AVE., STOCKTO ;CR 13 PERMIT NO.98 City Of Lodi Telephone (209) 466-6781 DATE ISSUED 3 P.O. BOX 320 PERMIT EXPIRES I YEAR FROM DATE ISSUE r.J,j i0AQUFN 1-OCAL Lodi , CA 952111 {Complete in Triplicate) HEALTH DIS 1 RIGT Attn : Mark Lindseth Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work.herein j 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. Job Address Subdivision Name i ' Phone 369-177S Owner's Name Paul Gerdes _ Address P.O. BOX 2S Lodi CA phone IF -118 Contractor's Name Henn in g Bros License No. 2 081 r TYPE OF WELL/PUMP WORK: NEW WELL C] WELL REPLACEMENT 0 DESTRUCTION ` PUMP INSTALLATION [] SYSTEM REPAIR OTHER [X] .Test Well F DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE Ori FOUNDATION AGRICULTURE WELL OTHER WELL 200 PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Industrial open Bottom E]Manteca Dia. of Well Excavation ri [� Domestic/Pri-vate O'Gravel Pack --rTTracy Dia.- of Well Casing f 17 Public Other [ Delta Type of Casing U Irrigation 600_, Approx. ❑Eastern Specifications Test Well Cathodic Protection Depth Depth of Grout Seal 1-1 Geophysical Type of Grout Xother Test Well E Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Ori l I for sand & water samples_ Well Destruction U Well Diameter Sealing Material (top 501) Depth Filler Material (Below 501) TYPE OF SEPTIC WORK: NEW INSTALLATION U REPAIR/ADDITION [j- (No septic tank or seepage piavai ableewithinubl200cfeet.sewe) is Installation will serve: Residence _ Commercial Other Number of living units: Number of bedrooms Lot size • Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. Type/Mfg Capacity Method of Disposal r. r Distance to nearest: Well Foundation Property Line LEACHING LINE Lf No. & Length of lines Total length/size FILTER BED Distance to nearest; Well Foundation Property Line SEEPAGE PITS Cj Depth Size Number SUMPS U Distance to nearest: Well Foundation _ Property Line i DISPOSAL PONDS F 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 rules and regulations of the San Joaquin Local Health District. 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 employ any person in such manner as to become subject to workman compensation laws of California." Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work for which i this permit is issued, I shall employ persons subject to workman's compensation laws of California." The ap ant must call f ll required inspections. Complete drawing on reverse side. Signed X Title: l.. Date: a4f 0 DEPARTMENT USE ONLY -Stk 466-6781 Application Accepted by A a Additional Comments: Lodi, g 369-3623 Pit or Grout Inspection ate Manteca 823-7104 -tf9" Final Inspection by Date D [] Tracy 835-6385 i Applicant - Return all copie to: Env ronmental Health Permit/Services 1601 E.Oaelton Ave., P.O. Box 2009, Stk.. CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PER+MIT NO. INFO 3.J�L�� EH 13-24 REV. 10/82 I0/82 S00 14-26