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R APPLICATION FORPERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT t� ��kf 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone 1209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (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 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. 4 Job Address 15.11 1A I N. Clements Rd' City Lodi Lot Size PM Owner's Name James Botsford Address 19909 E. Comstock Rd. 'Phone Contra ctot uryiance Drillers,p,d c-. P. 0. Box _64,Lind ggense No. 377923 Phone 887-3554 II TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT L] DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR�PC OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK .SEWER LINES DISPOSAL FLD. PROP. LINE f FOUNDATION AGRICULTURE WELL OTHER WELT PITS/SUMPS ' INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS C-]=lntfustriaF �-- ❑ Open-Bottom-----G-Manteca--.—Dia.of Well Excavation m--- Dia;-of_Well�asing C� Domestic/Private 1 ❑ GfaVel Pack ❑ Tracy Type of Casing st-ee `'� Specifications 1`1 Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout. X1 Irrigation __Approx. Depth I 1 Eastern Surface Seal Installed by - Repair Work Done ❑ Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material (top 501 _ Depth' Filler Material (Bei6w 501 `pit TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I i DESTRUCTION-III (No septic system permitted it public sewer is s. available within 200 feet) Installation will serve: Residence_ Commercial_ Other a. Number of living units: Number of bedrooms zy A`*,Character of soil to a-derth'of 3 feet: �"� Water table depth SEPTIC TANK ❑ TypelMfg.. Capacity No. Compartments PKG. TREATMENT PLT. LJ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑r Distance to nearest: Well Foundation Property Line SEEPAGE PITS l I Deptti Size Number _'SUMPS ---L'1--Oistance-to-nearest— Well-- ""Foundation' -PropertyLine""'-s"`� DISPOSAL PONDS ❑ fE 1 hereby certify that I have prepared this application and that the work will be done in accordance�% i!W San Joaquin county ordinances, state laws, and S rules and regulations of the San Joaquin Local Health District. k 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 no"' . I employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature/ I 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." 1 r The appli t must c�lLfor I r q re nspections. Complete drawing on reverse side. signed= \ Title: President Date: 1/8/00 FOR DEPARTMENT USE ONLY Application Accepted b `i' Date AreaAlt ✓ Pit or Grout Ins pection by bate Final Inspection by Date 1 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. Haialton Ave., P.O. Box'2009, Stk., CA 95201 FEE i I INFO AMOUNT DUE AMOUNT REMITTED CASH CK V RECEIVED BY DATE PERMIT'NO. F 1�*q �.EH 13-21 tREV.t i n 51 EH 14-26 ^4