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APPLICATION FOR PERMIT ire" Y,ti, C j Ott SAN JOAQUIN LOCAL HEALTH DISTRICT * _ " 1601 E. HAZELTON AVE., STOCKTON, CA f Telephone (209) 466-6781 NOV 2 $ 19eg PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ENVIRr'IN" NTA T (Complete in Triplicate) ' 4 r`i , F, l;;, Application is hetehy 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 Sart 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 1 220_E_a_s_t_Y_ictor Road - City Lodi Lot Size PM Owncr's Name Overhead Door Corn Address 1 220 East Victor Road Phone209-334-4800 5729 f Sonoma Dr. Drilli Contractor $SK and As SociateA&essP1easan#-nn CA - 945_6_6LicenseNo1904.4_2 Phone 415-462-4000 TYPE OF WE NEW WELL ❑ WELL REPLACEMENT EI DESTRUCTION o Environmental PUMP INSTALLATION ❑ SYSTEM REPAIR 0 OTHER oil borings DISTANCE TO NEAREST: SEPTIC TANK �"- SEWER LINES "^' DISPOSAL FLO. PR P. LINE ---- FOUNDATION AGRICULTURE WELL i OTHER WELL 0- PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation AV — Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing —+ Specifications f"1 Public 1] Other f I Delta Depth of Grout Seal /15: Type of Grouth I 1 Irrigation ____, Approx. Depth I I Eastern Surface Seal Installed by Aiiir& T Repair Work Done E3 Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Seating Material flop 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION i I (No septic systern permitted if public sewer is, available within 200 feet.) Installation will serve: Residence— Commercial— Other FlIh !dumber 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 PLT. ❑ Method of Disposal T Distance to nearest: Well Foundation Property Line LEACHING LINE Cl No. & Length of lines _ Total length/size MFILTER BED ❑ Distance to nearest: Well Foundation __ Property Line „ I /� SEEPAGE PITS I I Depth Size Number I`/// SUMPS i_1 Distance to nearest: Well Foundation Property Line DISPOSAL PONDS (7 I hereby certify that I have prepared this application and that the work will he 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'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." 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 California." The applicant t II for r quired ins ctions. oomplgte drawing onreverseside. Signed X_ Title: • 'Q, Q�"..�13r Data: 1\ ZZ Fdt DEPARTMENT USE ONLY r Application Accepted by - '�! Date s 6Area Pit or Grout Inspection by /JeDate Final Inspection by Datey� Additional Comments jitK eaAI A- 'o G 0 Stk 466-6781 �L . 369 621 IJ Mantoca 8237104 0 Tracy 835 6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazotton Avtt., P.O. Box 2009, Stk_ CA 95201 FEE INFO AMOUNT DUE AMOUNT REm T£D S RECEIVED f3Y DATE PERMII'NO. •.EH 16 tREY.t i . EH t��26