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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL 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 weupump and the Rules and Regulations of the San Joaquin Local Health District. ,�,r, I !P�TY �1:2 City LODI Lot Size PM Job Address 34"'� Owner's Name Dorm VAIT J.-Ti�.LIBIT Address 4j W TUR)`rfiiA , Q__ Phone 36 9-_18-6 Contractor K a'IIIH GROSS Address PO BOX 1178 license No.377 85 Phone '— TYPE OF WELL/PUMP: NEW WELL k i WELL REPLACEMENT� DESTRUCTION>o PUMP INSTALLATION Q SYSTEM REPAIR ❑ i OTHER ❑ DISTANCE 70 NEAREST: SEPTIC TANK '.-� SEWER LINES`' DISPOSAL FLD. PROP. LINE JI I FOUNDATION AGRICULTIJRE WELL OTHER WE-LL- —PITSISUMPS---=—_ I i INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing G3+Domestic/Private �L7MCravel Pack L1Tracy Type of Casing �� Specifications I"1 Public i t Other ❑ Delta Depth of Grout Seal Type of Grout C—P.MP 1� I I Irrigation _.Approx. Depth t 1 Eastern Surface Seal Installed by Cnnti- i YJ H.P. State Work Done EAC,RAJ)0 PTT�''�i'r�S__ . Repair Work Done. L1 Type of Pump - Well Destruction. ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 '- TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 HI=PAIWADDITION I 1 DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet., f Installation will serve: Residence_ Commercial— Other - I Number of living units: Number of bedrooms f Character of soil to a depth of 3 feet: Water table depth i SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE LI No. length/size No. & Length of lines �'- .__► FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I 1 Depth Size _'Number SUMPS ❑ Distance to nearest: Well Foundation - Property Line DISPOSAL PONDS ❑ to 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 D%trict. Home owner or licensed agent's signature certifies the following: "I certify that in the per of the work for which this permit is issued, I shall not s of California Contractor's hiring or sub-contracting employ any person in such manner as to become subject to workman's compensation lawsignature 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." e The applicant must II for at] r red inspections. Complete drawing on reverse side. Signed X Title: OWN'Eh i ' Date: FOR DEPARTMENT USE ONLY f Data�^f Area Application Accepted by g /J at Final Inspect i by ' Date( Pit or Grou Inspection by �;� Additional Comments: ❑ Stk 466-6781 ❑ Lch 369-3621 ❑ Manteca -7104 s k ❑ Tracy'835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Haialton A`ve:, P.O. Box 2009, 5tk_ CA 95201 1 i FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. INFO f J r SSO r +.EH 13-24 IREV.1/n sr A �/ u I EH 14-2e [ t