SU0004587 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICTIV' 1601 E. HAZELTON AVE., STOCKTON, CA 1/ u Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED SEP Z 6 ��g� (Complete in Triplicate) NVIROPIMEWTAL WEALTH Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herePE14M l:il5gR4ralication is made in compliance with San Joaquin County Ordinance No.549 for sewage or No:1862 for welllpump and the Rules and Regulations of the San Joaquin Local health District. - I f Job Address 17390 Krbll Rd. City Lodi Lot Size PM Owner's Name GENE WHEELER Address 17390 Kroll Rd. , Lodi Phone Lockeford Contractor Goehring Pump _Address 17754 N. Hwy. 88 License No., 309031 Phone-727-5548 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIRXX 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 Dia. of Well Excavation Dia. of Well Casing j ❑ Domestic/Private ❑ Graver Pack ❑ Tracy Type of Casing Specifications ('I Public FI Other f1'Delta Depth of Grout Seal Type of Grout i i Iniljation Approx. Depth ( I Eastern Surface Seal Installed by Repair.Work Done �E] Type of Pump Sub. H.P. 2 State Work Done reblace � W/ Well Destruction Ll Well Diameter Sealing Material I.top 50') $�---.-ubme sible Depth. y Filler Material (Below 50') r TYPE OF SEPTIC WORK: NEW INSTALLATION # I REPAIR/ADDITION l I DESTRUCTION I I (No septic system permitted if public,sewer is available within 200 feet.) Installation will serve: Residence_ Commercial Other 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 neatest:. Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED C1 Distance to nearest: Well Foundation Property Line SEEPAGE PITS I ) Depth Size _ Number SUMPS L3 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 laws, and rules and regulations of the San Joaquin Local Health District. Home.owner or licensed ageis 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 sue inner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the followin —I ify that in the performance of the work for which this permit is issued,I shall employ persons subject to workman's compensa- tion laws of Califo i . The applicant m r all quired inspections. Complete drawing on reverse side. Signed X Title: Bk ]r'. Date: _09/23/88 FOR DEPARTMENT USE ONLY p Application Accepted by t - Date u Area Ar} i Pit or Grout Inspection by Date Final Inspection by _ Date! Additi6nal Comments: ❑ Stk' 466.6781 ❑ Lodi . 369-3621 0 Manteca 823.7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 i INFO �AMOUNT DUE AMOUNT REMITTED CK 0 RECEIVED BY DATE PERMIT NO. + EH 13-24lREV,tin sl EH 1 -26 I�-� $ 7