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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT ' 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR 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 5200 E. Sargent Road City Lodi Lot Size PM Owner's Name City Of Lodi Address Call Box 3006, Lodi , 95-241 _ Phone 333-6706 Contractor, Val 1 ey Dri 11 i ng Address R.O. Box 42, Gal t,95632 License No. 299383 Phone 369-2779 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES_ DISPOSAL FLO. PROP.-LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom D'Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack. acy Type of Casing Specifications f'1 Public ❑ Otherlta Depth of Grout Seal Type of Grout I I Irrigation --__Approx.� stern Surface SealInstalled by Repair Work Done ❑ Type of PumpH.P, State Work Done_ [ Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 50') —_ TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR/ADDITION I 1 DESTRUCTION [ I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial— Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth k SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments ` PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line I LEACHING LINE ❑ No. & Length of lines Total length/size (1� ''FILTER BED ❑ Distance to nearest: Well Foundation Property Line _ SEEPAGE PITS i I- Depth Size Number .. ~ SUMPS CI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS El ff1Y 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 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, 1 shall employ persons subject to workman's compensa- tion laws of California." I The appiicant ust call for all r quired inspections. Complete drawing on rev rse side. ` I Signed X Title: � Date: 45 2- Q� 1 OR DEPARTMENT USE ONLY 1 C ( Application Accepted by Date D Area A i Pit or Grout inspection by fJ� Date Final Inspection by Additional Comments:� TC�d >f.C�i 1l�r� � d � - , //<<t ��i9 r -. =�U-° y�- ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tr cy 835-6385 rX, Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 955201 r FEE I INFO MOUNT DUE AMOUNT REMITTED CASK RECEIVED BY DATE PERMIT'NO. t EH 13-241REV.liH51 �L� S d lD ! 0 EH 14-26