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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 3 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES TYEAR 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.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address 33 West Armstrong Road City Lodi Lot Size PM Owner's Name Bert Castelanelli Address 33 W Armstong Rd Phone 369-921 Contractor Clark Well Address 2024 E Charter WayLicense No. 31.7560 Phone 46207676 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR 2 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 [7 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑'Domestic/Private El Gravel Pack ❑ Tracy Type of Casing Specifications n Public n Other ❑ Delta Depth of Grout Seal Type of Grout — 1 I Irrigation ---Approx. Depth I 1 Eastern Surface Seal Installed by _ Repair Work Done -] Type of Pump 2hP H.P. State Work Done Repair check Valve Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 501 TY=PE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DEST;RUCTION,1 I (No septic system permitted if public sewer is available within 200 feet.) > tnstallation will serve: Residence_ Commercial_ Other + Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: r. 4L._, Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments Pk�G. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Liner LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property-Line -- - SEEPAGE PITS I I Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and0 rules and regulations of the San Joaquin Local Health i�trict. Home owns licensed agent's signature certifies the (lowing: "I certify that in the performance of the work for which this permit is issued, I shall not employ any pe son in suc nn as to b e subj t to workman's compensation laws of California."Contractor's hiring or sub-contracting signal certifies th fol wing: "I erti t t in t rmanc the work for which this permit is issued,I shall employ persons subject toWorkman's compensa- tion laws C lifornia." The applica st al for e 'ed n . C late drawi on reverse side. Signed X Title: S ec—Tres Data: 21. April 89 FOR DEPARTMENT USE ONLY (� Application Accepted by Date Area_ v Pit or Grout Inspection by Date Final Inspection by Date A6ditional 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 95101 / i FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. INFO CASH +.£H 13- (REV.t/ns) 2 � qx7 EH U- "'1 f.