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.;._��....��,�--mow•.•-�� .asp- --��-�^w«�n»:.... � ++rte —^+�*�' APPLICATION FOR PERMIT SAN JOAO.UIN'LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 4666781' PERMIT EXPIRES 1'YEAIR FROM DATE "ISSUED''' (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District fora 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. JobAddress 'Hi _'Highway 991 at-Harney. Lane• - Lodi* CA city'i_"odirl ',t.;64.*Lotsize 7: acres .. PM , a' �,c� tea, ..-.. .1 _ .Owner's Name - Chero _k Memorial Par:(AddressHiahwa 99 at Harne =lane in LO:1phone 334-461.3 Contractor Burton C." Shoup. Addre s L!.86i3 +E�'HarveSt\Rd , Uc nsi No�7C764C �/S ,e 368-3343 TYPE OF WELL/PUMP: NEW WELL *eY'. WEtL.REPL'ACEMENT'❑° 'DESTRUCTIO PUMP INSTALLATION Q SYSTEM_ REPAIR ❑ OTHER ❑ { `•r DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP LINE "{� FOUNDATION AGRICULTURE WELL•.e. ,OTHER-WELL" - PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ti '4' s�tl" (JJ El Industrial L1 Open Bottom 11 Manteca Dia. of Well Excavation Dia. of-Well'Casing �`r'= ' 'J a "91 Domestic/Private El Gravel Pack ❑ Tracy Type of Casing 1'"+_p Specifications y l 191 Public/ � ❑ Other ❑ Delta Depth of Grout Seal Type of.Grout 4 S., .';11�; IrrigationJApprax. Depth ❑-Eastern Surface Seal Installed-by Repair Work Done LI ! Type of Pump t u rb 1 n? H.P. ] 5 �.T�State Work Done ' '' Well Destruction 10t Well Diameter Sealing Material itop 50'I 4 # Depth Filler Material (Below 501 _ TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION,O {No septic system permitted if public sewer is ^ t.r 4 "available within 200 feei:) ' Installation will serve_ Residence Commercial " .r� Others 4 4. C' Number of living units Number df-bedrooms I Character of_soil'to a depth o#,3 feet:^'r° - ` - `,_' 1 Vila#er table depth- SEPTIC TANK j❑ �T p Type/Mfg + yp 9 Capacity No. Compartments PKG. TREATMENT PLT:❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE IL No. & Length of lines € Total length/size ; FILTER BED `A ❑ Distance to nearest. ;Well - Foundat'ion� Property,Line� SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: _ Well: Foundation Property Line DISPOSAL POND?25��I❑ I hereby certify that J.have prepared this application and that the work will be done in accordance with`San Joaquin county ordinances, state laws, an(• rules and regulations Qf the San Joaquin Local Health District. v 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 nota, employ any person in such manner as to become subject to workman's compensation laws of.California."Contractor's hiring or sub-contracting signature y 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-1 F tion laws of Californ' I r The applic t m call r all r ired i pections, Complete drawing on reverse side.�/ /�,/ Signed { Title: _�� f/y� t(.T�II'i . Date: --hZ FOR DEPARTMENT USE ONLY ----Appiication A-ccepted-by!`' —"""'s Pit or Grout Inspection by 7 _ Date �" I' Final Inspection•byDate `��qf a Additional Comments: N.. ❑ 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 20%, Stk., CA 95201 FEE ; INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. + EH 13-24(REV.1/95) EH 1425 r� �.. �4 1fi - IfF I