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11 -- #- 11 ,p� APPLiCATION.FOR PERMIT SAN JOAQUIN LOCAL-HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA i Telephone (209) 466-67$1 PERMIT EXPIRES 7 YEAR FROM.DATE ISSUED �' ;• '.tet (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 H compliance with Sari 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.- �� + �- 16 South aCherokee Job Address " "� Lodi 207 'x -1291 N/A „. City Lot Size PM Owner's Name Stephanie "Taffy" add�ess Phone 1045 South-Cherokee (209),_.369_4725 ewe � I Contractor Brown & Caldwell Address 723Street r SaCt0.. License Ivo. (916) , 444 012 { TYPE OF WELL/PUMP: Phone (� NEW WELL EJWELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR El OTHER C� I' yi ,—DISTANCE-TO NEAREST:-SEP71C-TANK-may--��-•=RgEyyER-LINES"'-"'� �"''"'—" � ` N A FOUNDATION DISPOSAL FLD:PROP. LINE .F AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation . 1-1 Domestic/Private ❑ Gravel Pack El Tracy TYPe of Casing Dia- of Well Casing Ll Public Othe Public Specifications` (p �� r ❑ Delta Depth of Grout Seal ❑ Irrigation Approx. Depth ❑ Eastern Type of Grout pC` l Dr�9 k Surface Seal Installed by tk �ypie of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501) \ I Depth Filler Material {Below 501) TY OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ D RUCTION ❑ {No septic system permittedif public se r is available within 200 feet.) Installatio ill serve: Residence— Commercial� Other -� Number of livin its: I`, Number of bedrooms Character of soil to a th of 3 feet: { [ SEPTIC TANK ❑ /Mfg Water table depth PKG. TREATMENT PLT. LiI� Capacity No. Compart is Distance to rest: Well Method of isposal Foundation' ISM Prope ine I LEACHING LiNE ❑ fJo. Length of line FILTER BED Total length/ i e ❑ i stance to nearest: ell Foundation P erty Line SEEPAGE PITS ❑ Depth Size i umber .r.,. .Distance•to-nearest:..,,..:. SUMPS ❑� Well-- . oundation DISPOSA NDS ❑ �� Property Line I hereby dertify that I have prepared this application and that the work will be one in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the Sari 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 r quired inspections. Complete drawing on re rse side. Signed X J� _ Title: Date: f (� P SE ONLY Application Accepted b .i Date µ Pit or Grout Ins do y Dat"e —j Final Inspection by Date Additional Comments. ❑ Stk 466-6781 1-1 Lodi f 3621 ❑ Manteca 823-7104 ❑ Bey 835-6385 Q Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Bax 2009, Stk., CA 9520 INFO AMOUNT DUE AMOUNT REMITTED ,[` /� CASH RECEIVED BY' DATEQy� PERMIT'NO. i EH 13-24 Sp EV.3in51 �J ':�, -..3 S. (� `� : (�5,�� /V 4� '�-7"0 o EH T428 ��a7