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4 ta APPLICATION FOR PERMIT <br /> ? ' SAN JOAQUIN'LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON"AVE., STOCKTON, CA <br /> Telephone 12091 466-6781 a <br /> PERMIT EXPIRES 1'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 Ryles and Regulations of the San Joaquin <br /> Local Health District. • - r ^ - .. --• <br /> 11 .Job Address 1430 S. CHEROKEE LANE < < City LODI s �TLot'size800' x 400' PM <br /> Owner's Name-LODT TRUCK..SF VR ICE, INC Address K E _- Phone(209) 334-4�100- <br /> Contractor re WO F -. cense No. c D f v Phone V 31! <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION SYSTEM REPAIR ] OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK .500 SEWER LINES 600' DISPOSAL FLO.N NE PROP. EINE 1O0' <br /> FOUNDATION AGRICULTURE WELL V; OTHER WELL PITS/SUMPS <br /> I INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATION ash <br /> 41 <br /> Industrial LJ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Ox <br /> .Q <br /> Domestic/Private ❑.Gravel Pack ❑ Tracy Type of Casing Specifications <br /> is ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation --Approx. Depth ❑Pstern rface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. Si to Work Done <br /> Well Destruction LJ:' Well Diameter Sealing Material (top 50') <br /> Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system p rmitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence_ Commercial— Other <br /> i 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 ❑ Depth Size Number <br /> ' SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> 1 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 must c or all re uired inspections. Complete drawing on reverse side. DRAWING ATTACHED <br /> Signed Title: "-ASST- MANAGER Date: X26-85 <br /> «yA OR DEPARTME T USE ONLY # <br /> f Application Accepted by Date { Area 0 <br /> Pit or Grout Inspection by Date Final Inspection by Dates^ <br /> { 4 5 <br /> Additional Comments: _. _ ' - <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7144 ❑ Tracy 835-6385 <br /> Applicant- Return all copies to: Environmental Health Per 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE l INFO AMOUNT DUE AMOUNT REMITTED CK H RECEIVED BY DATE PERMIT'NO, <br /> 4 <br /> I + EH 13-24(AEV.t/95) - . T- `-^ 73p <br /> ' EH 14-26 <br />