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r APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 4 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.$49 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. "-Job_Address 12855 East Collier Rd. city Lodi Lot Size 5 Acres PM Owner's Name .1}OrtSide Builders Inc. Address 2714. C6untry Club #GPhone 466-071 t Contractor's Name Jerry Joy & Associate5License No. 394241 Phone 462-1481 TYPE OF WELL/PUMP: NEIN WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Indy trial. ❑ Open Bottom If Manteca Dia. of Well Excavation Dia. of Well Casing \ XI ❑o estic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ irrigation ----Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work pone Well Destruction ❑ Wellp Diameter Sealing Material [top 50') ! _ Depth Filier Material {Below 50') TYPE �``OF SEPTIC WORK:. NEW INSTALLATION C1L3REPAIR/ADDITION ❑ DESTRUCTION (No septic system permitted if public sewer is r Installation will serve: Residence A Commercial_ Other available within 200 feet.) Number of living units: 1 Number of bedrooms 3 Character of soil to a depth of 3 feet: Loam Water table depth 35' SEPTIC TANK ❑ Type/Mfg Capacity--1200No. Compartments 2 PKG. TREATMENT PLT. Cl "" / Method of Disp_osal Sedimentation Distance to nearest: Well" Foundation Property Line— _ ±r LEACHING LINE X1 No. & Length of lines D .`r Q a h Total length/size 120' FILTER BED El Distance to nearest: Well l�rl Foundation /U / Property Line. SEEPAGE PITS Xl Depth _25 i Size ' '� Num4er 3 SUMPS ❑ Distance to nearest:3. Well Foundation Aroperty Line DISPOSAL PONDS ❑ F 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 rules and regulations of the San Joaquin Local Health District. z 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 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." �-w ,r The applicant must call for all required inspections. Complete drawing on reverse side.'-' .r, Signed Title: Date: _� FOR DEPA TMENT USE ONLY y Application Accepted by 4X4:D Date Pito Grout Inspection by � Date C final Inspection by Date 1 D Additional Comments: ❑ Stk 466-5781 ❑ Lodi 369-3621 'fed❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK# RECEIVED BY DATE PERMIT`NO. INFO 1 CASH E + EH 13-24{REY.10/83) 45.00 5*00 �. O �� r -:S/ I EH 1428 `F:J L t`—"J^Fl--�' ...) / ", -3