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APPLICATION FOR PERMIT ,_. SAN JOAQUIN LOCAL HEALTH DISTRICT pq 1601 E. HAZEL T ON AVE., STOCKTON, CA PR' AfkAr?- Telephone (209) 466-6781 V�`b PERMIT EXPIRES TYEAR FROM DATE ISS ED �UG 519 (Complete in Triplicate) V341"4nrau Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install ed. This application is made in compliance with San1'Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules ,4;Pp the San Joaquin Local Health District. I Job Address 521 North Cherokee Lane City Lodi Lot Size PM I1450 Harbor Boulevard t RAMCOJI Inc: West Sacramento CA 95691 372-7535 Owner's Name Address _ Phone Contractor Trace Environmental Address 3084 Sunrise, Rancho Co>BtgYAINOCA 511740 Phone(916)638-804 TYPE OF WELLIPUMP: NEW WELL X1 WELL REPLACEMENT ❑ DESTRUCTION ❑ dMP INSTALLATION ❑ SYSTEM REPAIR ❑ OI�TAEl l jjCI��o'•c J DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP, LINE FOUNDATION --3TTr— — AGRICULTURE WELL NAOTHERWELL 3 0 PITS/SUMPS NA INTENDED USE IVYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑.Industrial d Open Bottom ❑ Manteca Dia. of Well Excavation 81, Dia. of Well Casing I ❑ Domestic/Private IX Gravel Pack ❑ Tracy Type of Casing PVC Sch 40 Specifications (`l Public �ppr... n Delta Depth of Grout Seal 30' Type of Grout cement/5% be to- I I Irrigation I I EasternSurface Seal installed by nite Repair Work Done ❑ Type of Pump H.P. State Work Done n, Well Destruction ❑ Well Diameter Sealing Material (top 501 ` Depth Filler Material (Below 5011 TYPE OF SEPTIC_ WORK: NEW INSTALLATION 1.1 REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is ry�l available within 200 feet.) . Installation will serve: Residence_ Commercial_ Other Number of living units: 1� Number of bedrooms _ Character of soil to a depth of 3 feet: Water table depth I SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Q Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size i FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I"I; Depth Size Number SUMPS ❑I .Distance to nearest: Well Foundation Property Line f DISPOSAL PONDS ❑: r I hereby certify that I have -Fre pared 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 t 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 mus all r "required in ctions. CotR.pleto drawing on reverse side. Ill Signed X r _ Title: Pr6 ject Geologist Date: 8/3/88 FOR DEPARTMENT USE ONLY i Application Accepted by , avi� cr—As Date a Ar a Pit or Grout Inspection by Date Final Inspection by ate Additional Comments: ❑ Stk 466-6781. ❑ Lo`Edi 369-3621 ❑-Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies;to: fnvironmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 K 0 INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. . +.EH 13-241REV.1/855 7 5 01 00 EH 14-2e I I