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tl APPLICATION FOR PERMIT .� it SAN JOAQUIN LOCAL HEALTH DISTRICT I� 1601 E. HAZELTON AVE., STOCKTON, CA ; I� Telephone (209) 466-6781 PERMIT EXPIRES TYEAR FROM DATE ISSUED I � (Complete in Triplicate) Application is hefeby 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. 'k Job Address 16440 DE V-RIMS RD City LODI Lot Size _ 1/3 ac PM f Owner's Name TI` mT_TI-7 Tn Address SAI Phone 369-7017 KET�T'H GROSS !� PO PDXx 178 � � Contractor Address License f�fo.37��a Phone�� s TYPE OF WELL/PUMP: NEW WELL-Z WELL REPLACEMENT ❑ DESTRUCTION PUMP INSTALLATION•ita- SYSTEM REPAIR ❑ OTHER ❑ s DISTANCE TO NEAREST: SEPTIC TANK 90 SEWER LINES DISPOSAL FLD.129 PROP. LINE .-40-- FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS 1 INTENDED USE TYPE OF!,WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ±11 Ll ❑ Open Bottom C1 Manteca Dia. of Well Excavation Dia. of Well Casing Domestic/Private Gravel Pack ❑ Tracy Type of Casing Specifications M Public n Other I�. ❑ Delta Depth of Grout Seal 4 Type of Grout I_P.Tnp-n-� I 1 Irrigation 160`—_Approx. Depth ( I Eastern Surface Seal Installed by nnntrar*`=`.nl^ I _ d Repair Work Done ❑ Type of Pump Sub H.P. I State Work Done DON ST-E N LY Wel! Destruction 1 Well Diameter 6 In Sealing Material Itop 50') Depth '1 32 Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW-INSTALLATION_1 I REPAIR/ADDITION [ I DESTRUCTION I 1 !No septic system permitted if public sewer is available within 200 feet.) Installation will server Residence I Commercial_ Other h , Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth - SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments 1 PKG, TREATMENT PLT. ❑ h Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines, .Total length/size FILTER BED CC' ' ❑ Distance to nearest Welles Foundation 1 �Prdperty.Line, r� � SEEPAGE PITS I I I Depth Size - — ^ Numbed SUMPS LI Distance to nearest: Well Foundation Property Line r DISPOSAL PONDS. ❑ I hereby certify,that t 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. ! 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.' 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 Ca'lifornia." �j r e i ;' The applicant must call for all required inspections. Complete drawing on reverse side. _ Signed X fIMITH GROSS,i Title:-. MINER Date: 23--�59 ` lyI -- - t II OR DEPARTMENT USE ONLY Appllceti Accepted by -----Date- - Area---- ✓' � (�-� � Pit oGro Inspection byq::2&,n Date oZ s Fine Inspection by / Data Additional Comments: '!.'-lc� �� f -' as r ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazalton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMn"No. INFO A +.EH13-21(RE � V.i i n 5Y `��- � EH 1♦-26 1 O6. a �7-Q lr