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k r APPLICATION FOR PERMIT SAN JOAQU-IN LOCAL HEALTH DISTRICT -: 1601 E. HAZE►ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED rl,-j�j _3Y• .-L ��.J X71 (Complete in Triplicate) fQ � �f Z.• �l Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described.:Th' application is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for ell/pump /and�thhee Rules a /�dul ions of t San Joaquin Local Health District. -�'2S7 rJ rLl, /7-R, SQQT- ��r�j � •1/�x 1 T rT /��++ Job Address test well l i r Sargent & CC trac tidy RR Lodi Lot Size 'T`' PM Ali Owner's Name City 0f Lodi Address 221 W Pine Street Phone 333-6706 Clark 2024 E Charter b0 6' Contractor Address License,NQ71 s Phone X62 b TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION PUMP INSTALLATION ❑ SYSTEM REPAIR LJ OTHER ❑ �� t DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE I FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom LJManteca Dia. of Well Excavation Dia. of Well Casing I ❑ Domestic/Private ❑ Gravel Pack Cl Tracy Type of Casing Specifications �l 71 Public ❑ Other I:1,Delta Depth of Grout Seal Type of Grout f i I irrigation _.-Approx. Depth l I Eastern Surface Seat Installed by _ F Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction Ja Well Diameter $if Sealing Material (top 50') 9 Sack Mix Sand & Cement Depth Filler Material (Below 501 IN I TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR/ADDITION I I DESTRUCT10li til lNo septic system permitted if public sewer is i� f available within 200 feet-i I. Installation will serve: Residence "I Commercial_ Other IFFF I Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth , SEPTIC TANK. ❑ Type/Mfg Capacity---------:, TNo. 'Compartments PKG. TREATMENT PLT- ❑ Method of Di a � sposal Distance to nearest: Well f=oundation Property Line LEACHING LINE ❑ No. &Length of lines Total length/size FILTER BED ElDistance to nearest: Well Foundation Property Line " - � I SEEPAGE PITS I I Depth Size Number SUMPS ❑ DistanceVto nearest: Well FoundationProperty Line DISPOSAL PONDS ❑ r ' 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. ,s i P Home owner or licensed agent's signatdre certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not r 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 s2,rUbAUvt in the performance of the,work for which this permiGis issued,1 shall employ persons subject to workman's compensa- tion laws of California." IX I � The applicant c I r ired ti n Co late drawing on reverse side, r .. � i4 Signed Title: Date: FOR DEPARTMENT USE ONLY Application Ac epted by � Date r Area - Pit rat �pectio7nbi bate incl Inspection r t Additional Commentsi,� d' +t+^- (.✓ F;�cJ �U tr—�� / � ❑ Stk 466-6781 ❑ Lodi -369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 l✓ Applicant- Return all copies to: E vironmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95261 v� 11/9ly ? t�'�� AhFEE w� cued INFO AMOUNT DUE AMOUNT REMITTED CK CASH RECEIVED BY 1`DATE PERMIT NO. S 1' 7-sJooS ♦ EH 13.24 1REV-I/9 5) EH 14-2e s