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APPLICATION FOR PERMIT , SAN JOAQUIN LOCAL HEALTH DISTRICT �°' 1601 E. HAZE T ON AVE., STOCKTON, CA p�� Telephone (209) 466-6781 NO,V 16 1992 PERMIT EXPIRES T YEAR FROM DATE ISSUED i iv,Y (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. ? �v 6:-. a�� T-3-N, VR-6^E, MDM LODI Job Address City Lot Size PM Santa Fe Pac,ifi,e Pipeline 888 SO . Figueroa St . Los Angeles Owner's Name Address Phone g pp �Contractor Glenn Martell 6 S1eS3Tnc , I181oyeri� e� enseNo. 510952 Phon451 43 — 82 TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION -0-- __ SY-STENLREPAIR ❑ OTHER>tT( G V' ` W DISTANCE TO NEAREST: SEPTICTANK F SEWER LINES Af rt E DISPOSAL FLD. s'% f PROP. LINE FOUNDATION AGRICULTURE WELL � OTHER WELL /:€'"<< PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavationl4 t t o 5 0 t Dia. of Well Casing rr EX Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing F4 8 0 Z Specifications 1"1 Public K Other ❑ Delta Depth of Grout Seal C& ft Type of Grout 7 slack _. I I Irrigation 300Approx. Depth I I Eastern Surface Seal Installed by slurry Repair Work Done ❑ Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter 1071 Sealing Material (top 501 Depth 300 1 Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_ Other 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 PKG. TREATMENT f I_T. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS t-1 Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation 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 Di§trict. 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." The applicant mustell for all rgquired ' spections. Complete drawing on r se side. Signed X L � Title: 07—i'� Com.- /1!9 SO Date: F0 DEPARTMENT USE ONLY Application Accepted by /"�',(GJ Date _ Area_ Pit or t rt Inspection by Date Final Inspection by �A� �� Date,,-/ 2 71 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. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AM UNT R MITTED OK EIVED BY DAT PERMIT'NO. r INFO H a.EH13.21(REV.1/x 5) 7457