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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE 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 well/pump and the Rules and Regulations of the San Joaquin Local Health District. o-y� i Job Address 'P-16`01 1SoAd s Rd. Lodi City Lodi Lot Size 40ac. PM Owner's Name Ralph Anderson Address 26190 Sowels Rda >a Phone r,ontractor Woods Well Drilligge,, 11944 Simmerhorn RdLicense No. 28 •8G J(1 Phone TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATIONXX SYSTEM REPAIR L7 OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK 1502 SEWER LINES 150, DISPOSAL FLD._50 PROP. LINE AM FOUNDATION 75 AGRICULTURE WELL 600 r OTHER WELL600 4 PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial )Open Bottom ❑ Manteca Dia. of Well Excavation / '-/Dia. of Well Casing $1 Domestic/Private ,'._Gravel Pack ❑ Tracy Type of Casing Steel Specifications 10 ❑ Public ❑ Other ❑ Delta Depth of Grout Seal 50=8 Type of Grout Sand Cetti en t ❑ Irrigation __—Approx. Depth h j❑ Eastern Surface Seal Installed by yes Repair Work Done ❑ Type of Pump H.P. `J State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 501 ` TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system m permitted if public sewer isavailab \� Installation will serve: Residence_ Commercial__ Other Number of living units: Number of bedrooms I 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 1 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 ❑ Depth Size Number SUMPS ❑ 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 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, I shall employ persons subject to workman's compensa- tion laws of California." The applicant must call for all requjred inspections. Complete drawing on reverse side. Signed X �_v Title: Contractor Date: 8, 789 FOR DEPARTMENT USE ONLY Application Accepted by Date Area Date Final Inspection by Pit or Grout Inspection by _ Additional Comments: JJ ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 CK#FEE AMOUNT DUE AMOUNT REMITTED ASH RECEIVED BY DATE PERMIT NO. INFO - ♦ EH 13-24(REV.t 8 9, /� �• �� V' �9 % �C tJ /.. �- < . EH 14-26 _. .. ..