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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTR ICT 1601 E. HAZE.--i ON AVE., STOCKTON, CA Telephone (209) 466-6781 E ISSUED PERMIT EXPIRES 1 YEAR FROM DAT (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.THs application is f an Joaquin made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations o the S Local Health District, Job Address Roger Raymond-13021 N Lower Sac Rd City' Lodi LotSize 5 acres PM Roger Raymond Address 13021 11. Lower Sac—Ed Phone 368-27?4 Owner's Name 462-5597 Contractor's Name Clar.k Well & Equip License No.371560 Phone Q�o TYPE OF WELL/PUMP: -- NEW WELL M WELL REPLACEMENT'-0. DESTRUCTION 0 PUMP INSTALLATION 0 .--SYSTEM REPAIR 0 OTHE13 Cl DISTANCE TO NEAREST: SEPTIC TANK ?5 f SEWER LINES -L-0—6 -DISPOSAL FLD/' ' PROP. LINE +100 f "I FOUNDATION — AGRICULTURE WELL — OTHER WELL-3k--f—t PITS—/SUMPS — INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 11 Casing 6 ca Dia. of Well Excavatiol---341 n Lft- '-'— Dia. of We —5/8 0 Industrial El Open Bottom . E1 Monte Steel Specifications 10 9 J�Domestic/Private N Gravel'Pack EJ Tracy Type of Casing- 0 Public 0 Other 0 Delta Depth of Grout Seal 50 ft Type of Grout (9 sack mi 0 Irrigation --Approx, Depth C1 Eastern Surface Seal Installed by Clark Weli Repair Work Done 0 Type of Pump Sub H.P. 1-fL;, ._ State Work Done install Well Destruction 0 Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTiC WORK: NEW INSTALLATION LJ HEFAIHIADDITION D DESTRUCTION 0 (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 Water table depth Character of soil to a depth of 3 feet: Capacity_ No. Compartments SEPTIC TANK 11 Type/Mfg Method of Disposal PKG. TREATMENT PLT. 0 Property�ine Distance to nearest: Well Foundation Total length/siz LEACHING LINE 0 No. & Length of lines FILTER BED El Distance to nearest: well Foundation— Property Line SEEPAGE PITS 0 Depth Size Number sumps 0 'Distance to nearest: Well Foundation— Property Line DISPOSAL PONDS 0 I hereby certify that I have prepared this application and that the work will be done in accordance With San Joaquin county ordinances, state la;,, and rules and regulations of the San Joaquin Local Health District. ormance of the work for which this permit is issued, I shall nott' Home owner or licensed agent's signature certifies the following: "I cortify that in the perf 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,I shall employ p6rsons subject to workman's compensa- tion laws of California.". reverse side. all The applican call r 11 s cti wing on _ I Contractor, Date: Jan 1285 Signed Title- FO DEPARTMENT USE ONLY ? - X-5 Area 14-2– if 5 Application Accepted Date by Date ct. y 695 85 Final Inspection by Pit or(Gr. n by Date Additional Common 0 Stk 466-6781 0 Lodi 0 Manteca 823-7104 0 Tracy Applicant- Return all copies to: Environmental Health Pernfit/Services 1601 E. Hazelton Ave., P.O. Box 2DO9, Stk., CA 95201 I CKS FEE AMOUNT DUE AMOUNT REMITTED RECEIVED B DATE PERMIT`;NO.' INFO CASH + EH 3-24 MEV.10/83) EH 114-28