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I =, APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT , 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES '{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 compkiance 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 640 N. Stockton Street City Lodi Lot Size 30 ' X 90 ' PM Owner's Name City Of. Lodi Address 221 West Pine St. , Lodi Phone (209) 334-5634 3429 Longview Dr. (916) Contractor Beylik Drilling Address NO. Highlands _License No. 306291 Phone485-0792 TYPE OF WELL/PUMP: NEW WELL 0 WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK N/A SEWER LINES 10 0 ' DISPOSAL FLD, N/A PROP. LINE 2 0 r FOUNDATION NIA AGRICULTURE WELL NIA OTHER WELL N-A PITS/SUMPS N/A INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation A 0 11 Dia. of Well Casing 2011 ❑ Domestic/Private IN Gravel Pack ❑ Tracy Type of CasingCO r Bearing Specifications 9 Public ❑ Other ❑ Delta Depth of Grout Sea e 1 19 5 t Type of Grout acment k L.•'' 14 Irrigation ___Approx. Depth l I Eastern Surface Seal installed byTT��Bey lik Drilling an ce - Repair Work Done L7 Type of Pump H.P. Stet VVbrk Done ' Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 50') —_ t TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION l I DESTRUCTION I i {No septic system permitted if public sewer is i 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 SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line (� LEACHING LINE ❑ No. & Length of lines Total length/size/ FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number ! SUMPS Ll 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 l 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 st all for all required inspections. Complete drawing on reverse side. (SEE ATTACHED) Signed GEORGE COLLIER Title: Project Manager Date:danuary 23 , 1991 FO DEP RT ENT USE ONLY Application Accepted by PDate r � Area 2 Pit or Grout Inspection by Date Final Inspection by Date y Additional Comments: C ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-638 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 I CK 0 RECEIVED BY DATE PERMIT NO. INFO �f► c C}��/�/-7 CASH ♦.EH 1324IREV.t/n5) �� C — $3 a M a.13 -gi q/ _n � {I EH 14-20 CJ ]