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l APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT L 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Apprlcation is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described.This app8cation 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. APN• 047-353-08 Job Address 303 S_ Cherokee Lana City Lodi Lot Size PM 731 Birchwood Owner's Name Mr. Lloyd GUMSLAddress Edi, Ca. 95240 Phone 368-8080 The Training Laboratories P.O. BOX 1472 C57 L5. CIContractor Inc Address License No.SOt;1 59 Phone TYPE OF WELL/PUMP: NEW WELL O WELL REPLACEMENT ❑ DESTRUCTION — PUMP INSTALLATION O SYSTEM REPAIR O OTHER 0 Soil Borings DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE LFOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS O Industrial O Open Bottom ❑ Manteca Dia. of I7—inches— es Dia. of Well Casing L O Domestic/Private O Gravel Pack ❑ Tracy Type of asiinn None Specifications ('1 Public r_1 Other f1 Delta Depth of Grout Seal SUrfaCe I I Irrigation 2.W Approx. Depth I I Eastern Surface Seal Installed by Type of Grout Nkat Cement LRepair Work Done L1 Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter Seating Material Itop 50'1 t Depth Filler Material (Below 50') _ TYPE OF SEPTIC WORK: NEW INSTALLATION 1 I REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is tavailable within 200 feet.) Installation will serve: Residence_ Commercial_ Other Number of riving units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK O Type/Mfg Capacity No. Compartments PKG. TREATMENT FILT. O Method of Disposal Distance to nearest: Well Foundation Property Line LLEACHING UNE ❑ No. 8 Length of lines Total length/size _ LFILTER BED Cl Distance to nearest: Well Foundation Property Line SEEPAGE PITS 1 I Depth Size Number SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ L 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 D3trict. 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 Lcertifies 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 laws of California." The applicant mus c all required inspections. Complete drawing on reverse side. L Signed X ° Title: _prpjec-t GeQ3agist Date: 12/04/95 FOR DEPARTMENT USE ONLY Application Accepted by �"�"��" �+ 1 S s Date Area L Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: O Stk 466-6781 O Lodi 369-3621 O Manteca 823-7104 O 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 CK a RECEIVED BY DATE PERMIT NO. INFO CASH 1 .24(REV.t i 5) �. EH 14-26Oq