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}, APPLICATION FOR PERMIT ?/ SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone 1209) 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 4791 91 "SC OTTSD '1' City LODI Lot Size 6 AC PM 4 Owner's Name OAHOL O 01WON Address SAME Phone 339-4692 Contractor_% IITHGROS'S Address PO BOX 178 WOO:UBRIDUense No. 377385 Phone 334--4725 TYPE OF WELL/PUMP: NEW WELL;d 1,'; WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION,"{ SYSTEM REPAIR OTHER LDISTANCE TO NEAREST: SEPTIC TANK SEWER LINES 33 f eO ISPOSAL FLD. PROP. LINE &I eet FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well,Excavation JMc Dia.`of Well Casing 6 7_n N J .„'M„ni bomestic/Private 'k Gravel Pack ❑ Tracy Type of Casing PW Specifications I FI Public ❑ Other ❑ Delta Depth of Grout Seal 100 Type of Grout � I I Irrigation _..Approx. Depth I 1 Eastern Sutface Seal Installed by - - 1�. Repair Work Done ❑ Type of Pump SUB _ H.P. 5 h_ State Work Dane Well Destruction ❑ Well Diameter Sealing Material (top 50') -- R Depth Filler Material (Below 50'1 `C TYPE OF SEPTIC WORK: NEW INSTALLATION [I REPAIR/ADDITION I I DESTRUCTION l I (No septic system permitted if public sewer is 1t available within 200 feet.) r 1 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 SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Pro&rtV.Line l LEACHING LINE ❑ .No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line 4 SEEPAGE PITS I I Depth Size Number SUMPS LZ 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 f 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,l shall employ persons subject to workman's compensa- tion laws of California." The applicant must call for all requirA inspections. Complete drawing on reverse side. Signed X Title: Date: 12-17-88 88 4FOR DEPARTMENT USE ONLY l Application Accepted by 1 Date C Area- D Pit or Grout Inspection b�yv Date Final Inspection by «ft 2 Date L�3 /)2mAdditional Comments: _ /�� ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7144 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E, Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED K RECEIVED By DATE PERMIT'NO. INFO +.EH 13-24(pEv.IIh5) -!�-1 EH 14-2e 1 t q