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• APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, �,'QN JOAQUIN LOCAL I-li-ALTI-11 DISTRICT Telephone (2091466-6781 ENVIRONMENTAL HEALTH DIVISION PERMIT EXPIRES 1 YEAR FROM DATE ISSUED SPECIAL PERMIT (Complete in Triplicate) all the work . This cation made in complliance wieby th San Joaquade to the in County Ordinance uin lNth District for a o.549 for sewage or permit No. 1862 forcwell/dpump atnd the Rules and herein Regulations of the Sao Joaquin Local Health District. 1220 East Victor Road City Lodi Lot Size PM — Job Address __ I OVERHEAD DOOR CORPORATOddreo ss 1220 E. Victor Road, Lodi,_CA - Phone(`209) 334-4800 Owner's Name —T -- t BSK & ASSOCIATES 5729—F Sonoma Dr. C57 490942 (415) 462-40 )0 Contractor Address Pleasanton. CA 94566 _License No.__. Phone_ TYPE OF WE[ /PUMP: NEW WELL I� On1 Oleg REPLACEMENT 11 DESTRUCTION 11 PUMP INSTALLATION � SYSTEM REPAIR Cl OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK � SEWER LINES - DISPOSAL FLD. PROP. LINE FOUNDATION ___ AGRICULTURE WELL _— OTHER WELL — PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS (see attached drawings) Ell Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation -- Dia. of Well Casing fl Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing—._ _ Specifications I.1 Public X1 OtherMonitoringi Delta Depth of Grout Seal -____ -- Type of Grout - I I Irrigation _.Approx. Depth I I Eastern Sminee Seal Installed by------ Repair y_ — —Repair Work Done ❑ Type of Pump —_ H.P. —___---- State Work Done Well Destruction ❑ Well Diameter — Sealing Material Itop 501 --- ------ Yv 1 Depth __ Fnler Material (Below 501 -- -- --- (7 TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR,ADDITION I I DESTRUCI ION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercia. ___ Other Number of living units: — Number of bedrooms_._.—_— r Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK Ll Type/Mfg ____—_ Capacity_ _._- No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Weli —__— Foundation Property Line LEACHING LINE ❑ No. & Length of lines __-- Total length/size FILTER BED 1-3 Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number - SUMPS LI Distance to nearest: Well Foundation __— Property Line _ DISPOSAL PONDS 17 I hereby certify that 1 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 Diktrict. 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 10 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 iia." The applican us call d i pections. Complete drawing on reverse side. — Signed _ --.._.__-.— 1 isle: _ Engineering Geologist Date: 5/9/89 FOW*PAR T USE ONLY Date gree Application Accepted by �— —[ Pit or Grout Inspection b �� Date rP/1 Final Inspection by :. / •' � •-t^T�6r Date j ' y r� 1(I�I�� Additional Comments: '� -/ � 4' �L �E L{ i� ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 923-7104 ❑ Tracy 83� _ Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 nE!!!=AM __FMZD RECEIVED BV DATE PERMITNO. 112b24 IREV.r/xw / , '�- EH 1428