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s 41 APPLICATION FOR PERMIT / SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA .Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED f� (Complete in Triplicate) Application is hereby made to 06 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 Jo6quin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. S 1'. Central Ave.- -LOdi Job Address �2 3d + • City Lot Size PM �� - 1230 So Central Ave, Lodi 368-5341 Owner's Name Lodi Academy H.S. Address Phone ? Contractor's Name WDodd Well DrillilAgrise No. 282866 Phone 745-2407 ?—T.Y.P-E_OF W.ELLIPUMP_:�_-1,-! -NEW WELL ❑. ❑ --;-z!-DESTRUGTION-❑--- -----'«� --- PUMIP INSTALLATION i( SYSTEM REPAIR ❑ 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 fDia. of Well Excavation Dia. of Well Casing:, ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy ;Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout Irrigation �pprox. Depth ❑ Eastern Surface Seal Installed by epair Work Done ❑ Typel�of Pump �� H.P.15 c d State Work Done Mett-I 1 Well Destruction ❑ Well Diameter Sealing Material (top 50') 1 = Depth Filler Material{Below 501 --- L TYPE OF SEPTIC WORK: NEWINSTALLATION Cl.. REPAIR/ADDITION ❑ DESTRUCTION ❑.-(No septic system permitted if public sewer is 11j available within 200 feet.) Installation will serve: Residence_ Commercial_ Other " Number of living units: Number of bedrooms f Character of soil to a depth of 3 feet: Water table depth a SEPTIC TANK - ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ 11- Method of Disposal Distance to nearest: Well Foundation Property Line �. LEACHING LINE ❑ Nlo. & Length of lines Total length/size � FILTER BED ❑ Dis�itance to nearest: Well r Foundation Property Line ;e- SEEPAGE PITS ❑Depth,= _S-ize Number *�t SUMPS ❑ Distance to nearest: Well Foundation Property Line f .DISPOSAL PONDS E) .1I. I hereby certify that I have prepired this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the Saril'Joaquin Local Health District. Home owner or licensed agent's:isignature 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.' i�The applicant must call for all requi ed inspections. Complete drawing on reverse side. 19$6 Signed X r � � i Fitle;�-_vn ler ; Agit 17 FOR DEPARTMENT USE ONLY • ,• : { 'rD Application Accepted by ate _ Yn 61%rea 2t / t Pit or Grout Inspection by I� Date Final Inspection by Additional Comments: ❑ Stk 466£781M'389-3621 ❑ Manteca 823-7104 �❑ Tracy 835-6385 Applicant- Return all copies to Environmental Health Permit/Services 1601'E. Hazelton Ave., P.O. Box 2009, 95Z0w FEEAMOUNT,DUE AMOUNT REMITTED RECEIVED BY DAT PERMIT"NO. INFO ryI ' Y+ EH1324(REV:10183) ' EH 14-26