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• APPLICATION�FOR PERMIT - f SAN JOAQUIN "LOCAL HEALTH DISTRICT 1601 E. HAZE TON AVE., STOCKTON, CA Telephone I209f 466-6781 . PERMIT EXPIRES 9 YEAR FROM DATE ISSUED ti- (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. 1662,for well/pumpland the Rules and Regulations of the San Joaquin Local Health District. II�+ eN t Hdon School'-Hayne Lane SCo.J.-- C 's ' Job Address enersy Lot Size - PM i "owner's Name Lodi Un1fiedRSchoo1 I Address 815 'W. Lockeford Lodi Phone District' Stockton Contractor Clark Well Address 2024 H. Charter License No, Phone 462-5597 E TYPE OF WELL/PUMP: I NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ i PUMP INSTALLATION ❑ SYSTEMREPAIR ❑ OTHER X] Test Well 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 >p ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Vr_ .4 $ ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public 01 Other ❑ Delta Depth of Grout Seal � Type of Grout ❑ Irrigation 41.5 .'I Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done El Ty:! of Pump H.P. tate Work Done eS e r togging wa er bearingstrata + Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50') o ai ning water samples f0 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) installation will serve: Residence_ Commercial_ Other 1 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 k :PKG. TREATMENT PLT. ❑ ,I�I x Method of Disposal d Distance to nearest: Well Foundation Property Line S LEACHING LINE ❑� No. & Length of lines 4 r Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 0 Depth ASize Number F 0 1 s SUMPS ❑ Distance to nearest:" Well - Foundation t Property Line DISPOSAL PONDS ❑ 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. Home owner or licensed agent'is 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." // The applicant ust call for all require inspections. Complete drawing on reverse side. �lp� Signed X �M Title:' Pro j ect Engineer Date: 4/24/87 K ' ldsen-Sinnock & Associates, Inc. s FOR DEPARTMENT USE ONLY n Application Accepted by I 1 Date �` Area—/J/ Pit or Grout Inspection by " Date Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 C1 Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O..Box 2009, Silk., CA 95201 FEEAMOUNT DUE AMOUNT REMITTED K RECEIVED BY DATE PERMIT'NO. INFO 0Ir rC///ASH60 + EH 13-241REV.F/x51 EH 14-28