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i - §, APPLICATION FOR PERMIT SAN JOAaUIN LOCAL HEALTH DISTRICT AYMENT `x'1601 E. HAZEL T ON AVE., STOCKTON, CA RECEIVED Telephone (209) 466-6781 X 9930 P 19909 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED SAN 10A COUNTY (Complete in Triplicate) EN P�p1�n�l31^yL�IIC �HJ�E,jA�L��T�,H SEPI' `I(,,-S�{ he 1,11 N f19�t�f1�Qe9Crf&Abu�rli 6loNon is Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the wor i 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 225 South Cherokee Led City Lodi Lot Size PM Owner's Name Arco Products _y Address P.O. Box 5811 San Mateo CA Phone 415-571-2434 JilliContractor Wade ng_Address P.O. Box 726 Lincoln License No. 376345 Phone 916-965-93E5 I WELL REPLACEMENT ❑ DESTRUCTION L3TYPE OF WELL/PUMP: NEW WELL C1P17�'MP INSTALLATION ❑ SYSTEM REPAIR ElOTHER Soil boring DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. POOP. LINE dl: 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 ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications FI Public [7 Other F Delta Depth of Grout Seal Type of Grout sementZbmtc nit( I I Irrigation J. _Approx, Depth L) Eastern Surface Seal Installed by - Repair Work Done L3Type of Pump H.P. State Work Done_ I l Well Destruction ❑ Well Diameter Sealing Material [top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIR/ADDITION LI DESTRUCTION l I (No septic system permitted if public sewer is Q . 1 n� available within 200 feet.) ' Installation will serve: Residence_ Commercial_ Other Al—mber of living units: � Number of bedrooms � Character of sail to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments ' PKG. TREATMENT PLT. © Method of Disposal i Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines 11total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line (� SEEPAGE PITS l I Depth Size Number SUMPS Ll�: Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ji Y' 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 n 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." Contractors hiring or sub-contracting signature 1 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 musi call f 11 required inspections. Complete drawing on reverse side. Signed X Title: Project Geologist Date:Septffrber°�4�)?990 I - Eloise]Frick OR DEPARTMENT USE ONLY �} Application Accepted by �, `w' �/ — Date a Ar Pit or Grout Inspection by !!' Date 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. Sox 2009, Stk., CA 95201 k IFEE NFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. 00- .' +.EH13-24(REV.t/K51 J('70 0— ., •! �� - ` 70 I0~ V ✓. €