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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 2-009E. , STOCKTON, CA 91r?_01 Telephone (209)4664-AM Voll• 3 L12.,p PERMIT EXPIRES 'i YEAR FROM DATE ISSUED V` (Complete in Triplicate) Application is hereby matte to the Sat!Joaquin Local Health District for a permit to construct andlor 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;- Job Address 44 .S. Rose Street City Lodi Lot Size 10 Acres PM P. 0. Box 3006 Owner's Name City of Lodi Address LodiCA 95241 Phone 2091 334-5634 Maggiora Bros. 595 Airport B1Vd. Contractor Address License No. 24995';'. __Phon(4 TYPE OF WELL/PUMP: NEW WELL X) WELL REPLACEMENT L1 DESTRUCTION ❑ PLIMP (INSTALLATION 171 ,_ SYSTEM REPAIR ❑ -,.:-.__�THER ❑ DISTANCE TO NEAREST: SEPTIC TANK N SEWER LINES DISPOSAL FLD. N A PROP. LINE 50C FOUNDATION 100' AGRICULTURE WELL N/A OTHER WELL N A PITSISUMPS - A INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS !t ❑ Industrial El Open Bottom ❑ Manteca Dia. of Well Excavation 32 It Dia. of Well Casing 2 r ❑ Domestic/Private IXGravel Pack ❑ Tracy Type of Casing Steel Specifications Public ❑ Other (7 Delta Depth of Grout Seal 93 Type of Grout 10._Sc3Ck I I I Irrigation 343.�Apprax. Depth i I Eastern Surface Seal Installed by Drill -r Repair Work Done ❑ Type of Pump H.P, State Work Done— q Well Destruction ❑ Well Diameter Sealing Material (top 501 — II Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I.1 REPAIR/ADDITION ;.I DESTRUCTION l 1 I Noava septic system permitted if public sewer is J available within 200 feet.) 31 Installation will serve: Residence Commercial_ Other a I Number of living units: Number of bedrooms k Character of soil to a depth of 3 feet: Wat t gp,�h AN-a SEPTIC TANK ❑ Type/Mfg Capacity i ii�+F d PKG. TREATMENT PLT. ❑ McREW s I Distance to nearest: Well Foundation Property kirle P--�2 LEACHING LINE ❑ No. & Length of tines Total lengthWJ JOAQWN COUNTY I FILTER BED LJ Distance to nearest: Well Foundation Lf�i i INMr,, � t � Ll, DIVISION �SEEPAGE_PITS-�I,I--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 Diltrict. 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 taws of California." The applicant must call for "requiredi spectionst Complete drawing on reverse side. Signed x Title: Contract Administrator Date: 09-28-92 i FOR DEP T, E ONLY 12 Q Z Application Accepted by Date �� 1 Area Pit or Grout Inspection by r bate Final Inspection by Date Additional Comments: ElStk 466-6781 ❑ Lodi 369-3621 C3Ma eca 823-7104 0 Tracy 836- 5 r t Applicant - Return all copies to: Environmental Health Pe mit/Services 1601 E. Hazelton Ave., P.O. Box 2009 Stk., CA 9 I LJ FEE JrUNT DUE AMO REMITTED CK RECEIVED BY D TE PERMIT'NO. INFO I +.E.r. tREV.t/H611 Et