89-1198 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT ^ . 1 SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) 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 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 55 East Harney Lane city Lodi Lot Size PM Owner's Name City of Lodi Address 221 West Pine Phone j 306291 Phone(916)485-079 Contractor Bey �k Drilling, ne,Address 3429 Longview Or.. License No. TYPE OF WELL/PUMP: NEW WELL IX WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION 0 SYSTEM REPAIR ❑ OTHER ❑ ' DISTANCE TO NEAREST: SEPTIC TANK nZ.d SEWER LINES . n/a DISPOSAL FLD. PROP. LINE FOUNDATION --n/—a AGRICULTURE WELL nd OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS i ❑ Industrial C] Open Bottom © Manteca Dia. of Well Excavation Dia. of Well Casing 2011 j 0 Domestic/Private CK Gravel Pack ❑ Tracy Type of Casing Steel Specifications X Public F1 Other ❑ Delta Depth of Grout Seal 185, Type of Grout Aeat—Ce nme t� I Irrigation S�-Approx. Depth I I Eastern Surface Seal Installed by Contractor _ �t�� Repair Work Done ❑ Type of Pump H.P. State Work Done — " , Well Destruction ❑ Well Diameter Sealing Material [top 501 Depth Filler Material (Below 50') -- TYPE OF SEPTIC WORK: NEW INSTALLATION ['I REPAIR/ADDITION I 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: Wor SEPTIC TANK ❑ Type/Mfg Capacityiio��mpartment PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Proper�}� LEACHING LINE ❑ No. & Length of lines Total length/size Ty� FILTER BED ❑ Distance to nearest: Well Foundation FrEWWONMENTALHEUTH PERWISERVI ES SEEPAGE PITS i I Depth Size Number SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ r 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's 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 this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." The applicant must call for all required inspections. Complete drawing on reverse side. Signed X .� __ Title: Project Manager Date: May 15, 1989 Day i d .S, Bards y FOR DEPARTMENT USE ONLY 6 rr P� Application Accepted by Date k7 1 Area �61 -3 Pit or Grout Inspection by Date�t7 � Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ 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 95201FEE INFO AMOUNT DUE AMOUNT REMITTED K H RECEIVED BY DATE PERMITNO. +.EH 13-24(REV.t i K 5Y 1 £H 14-2e