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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, §A)q JOAQUIN LOCAL HEALTH DISTRICT Telephone (209) 466-6781 ENVIRONMENTAL HEALTH DIVISION PERMIT EXPIRES 1 YEAR FROM DATE ISSUED SPECIAL PERMIT (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. Job Address 1220 East Victor Road City Lodi Lot Size PM Owner's Name OVERHEAD DOOR CORPORATIONddress 1220 E. Victor Road, Lodi, CA phone 209 334-4800 BSK & ASSOCIATES 5729—F Sonoma Dr. C57 490942 Contractor Address Pleasanton, CA 94566 License No. Phone(415) 462-40 0 TYPE OF WELL/PUMP: NEW WELL 9 mortlLtOA4M REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION Ll SYSTEM REPAIR L1 OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK _ /,1SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS (see attached drawings) ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications Cl Public 10 OtherMOnitoringl Delta Depth of Grout Seal Type of Grout_. 1 I Irrigation —Approx. Depth t I Eastern Surface Seal Installed by _ Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: .NEW INSTALLATION I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_ Other zf{ Number of living units: _ Number of bedrooms I`I Character of soil to a depth of 3 feet: Water table depth r 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 1 1 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 workwill be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health DiMrict. 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 Califor ia." The applican us call Y i 'r(id i pections. Complete drawing on reverse side. Signed �' Title: Engineering Geologist Date: 5/9/89 FOR 'PA V T USE ONLY Application Accepted by n Date Area Pit or Grout Inspection by� /V Date FFii�nall lnssp�ecttion b/y / Date Additional Comments: �!'S"di�-J1�1.'0/i1. 'fS v w l f,c.�V�f tM. d1A : 5/A pY.� ❑ 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 FEEgMOUNT DUE AMOUNT REMITTED', RECEIVED BV DATE PERMIT NO. INFO ,.EH 1124 IREV.1/.slC ^ EH 1428 C` ty� SQ i q b