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r' APPLICATION FOR PERMIT SAN JOAQUIN"L'OCAL HEALTH DISTRICT' 1601 E. HAZEL T ONhAVE., STOCKTON CA' S}" Telephone (209) 466.6781 PERMIT EXPIRES 1 YEAR'FROM DATE ISSUED '' (Complete in Triplicate)"° t, t1 '''-t..! Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described..TNs application is made in compliance with San Joaquin County Ordinance No.549 for sewage`or No. 1862 for well/pump and the Ryles and Regulations of the San Joaquin Local Health District. r 1. !!J.. c..'� 1. t' - ' . �_ " w_.' Y `a ",.�� ` *, •t n�O ( b3U- (07 Job Address Hi hway 99:,,at~Hayne Lane;' Lodi- CA , 'Dodi-0 - '+ City Lot Size 7 a C re S PM Owner's Name Chero.:k Memorial Pa-rkAddressHiahvaay 99 at i�arney 'lane 'in-Lo none 334-96i 3UrtOn C. ShoU �" 'ts+', . fy i� t1 ►. Contractor Address ��'�• 1,arVeSt Rd. License No3'76764C.�TSr ,e 368-UJ-) " r TYPE OF;WELL/PUMP: NEW WELL 1 f' J*,.T WELL.REPLACtMENT'❑' DESTRUCTIO r a PUMP.INSTALLATION M SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE s FOUNDATION AGRICULTURE WEL-L_� ** OTHER-WELL', PITS/SUMPS x INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS.* � � f } 1 LlIndusttial i ID Open Bottom F-1MantecaDia. of Well Excavation r Dia. of 1Nall'Casing E ' v.S�• ` ] Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing '? e - Specifications 1 ' PublicI ❑ Other ❑ Delta Depth of Grout Seal Type of.Grout S! i'l Irrigation ---Approx. Depth ❑-Eastern Surface Sea_I lilstalled-by . Repair Work Done ❑ Type of Pump tUrbi n- H.P. 15 k `S_ta a Work Done f Well Destruction I Well Diameter Sealing Material {top 50'1 i Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION,❑ (No septic system-permitted if public sewer is ` 'available within 200 feet.) I Installation will"serve-1 Residence - Commercial+ Other Number of living units' `y !Number of-bedrooms 1 ° t I Character of,soil`to a depth of;'3 feet '' '- t ,t. .- Wat'ertable depth, , SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments l PKG. TREATMENT PLTi❑ Method of Disposal x Distance to nearest: Well Foundation Property Line 0. Tra LEACHING LINE ,f` ❑ No.'& Length of lines . - ~� Total,length/size d " JS FILTER BED 4 C] Distance to nearest: 'Well Foundati6n6 �Property,Line;r T'+ r �. SEEPAGE PITS ❑ Depth Size Number SUMPS El to nearest: Well FoundatiorlA . S ❑ Property Line DISPOSAL POND 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, andf' rules and regulations of the San Joaquin Local Health District. Home �- owner or licensed-,agent's signature certifies the following: "1 certify that in the performance of the work for which this permit is issued, I shall notes. 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 Ca1'rforn- . i The applic t m call r all r ired i pectiong, Complete drawing on reverse side. Signed Title: Date: I FOR DEPARTMENT USE ONLY s -.--Application A-ccepted-by�-- :�w', i Date Area rt �� " Pit or Grout Inspection by Date i'� Final Inspection•byg v/�-`'`�. �: . Date vg j Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6365 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 4 } FEE AMOUNT DUE AMOUNT REMITTED RECEIVED 8Y DATE PERMIT N0. INFO CASH + EH13-24 1REV..1/a 5) i ` t _ $'7•_1 fiH 14-26