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APPLICAT!ON FOR PERMIT ff <br /> SAN JOAQUIN LOCAL HEALTH DISTRIL76) <br /> 1601 E. HAZEL T ON AVE;, STO KTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Y..._..—{Complete in Triplicate} �- ----- <br /> 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 <br /> made in compliance with San Joaquin County Ordinance No.549 for sewaprr or No.1862,for well/pump and the Rules and Regulations;of the San Joaquin <br /> Local Health district: <br /> Job.Address 54{4 East Harney "Lane City Lodi eat size 110 acre PM <br /> Frank re ss <br /> Owners Name Color Spot Address _ Same Phone <br /> Consultant:Staal Gardner & Dunne c. 805 <br /> X�lrt'fr�iAof Address'.(l i bj. pit Q+_ F License oto..1qQ# A Phone. 5 5 r3 <br /> TYPE OF W€LLIPUMP: NEW WELL 0 WELL.REPLACEMENT0 DESTRUCTION <br /> PUMP INSTALLATION 0 SYSTEM REPAIR ,O OTHER IR Soil Vapor Survey <br /> DISTANCE TO NEAREST: SEPTIC TANK OQ+ _ SEWER LINES DISPOSAL FLP, PROP, LINE30.4_lt <br /> FOUNDATION UQ0_ 1- AGRICULTURE WELL 0— OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECiFICATIONS <br /> © industrial O Open Bottom 0 Manteca Dia. of Well Excavation tri f� Dia.of Well Lasing RPgeT <br /> M Domestic/Private ❑ Gravel Pack 0 Tracy Type of Casing 2OnA Specifications <br /> Pirh!!G Cl Other n Delta Depth of Grout Sealentirje__JnteZval TypeofGrout_ <br /> jol <br /> y-- <br /> I 1 Irrigation Approx. Depth t I:-Eastern Surface Seat Installed by <br /> llepair Work.D.one :0Type of Pump H:P; '!_ State Work Done_ <br /> Well Destruction: 0 Well Diameter . _ Sealing Material (top 50') vO1cl ! <br /> Depth Finer Material (Below 501 <br /> TYPE Of SEPTIC WORK: NEW INSTALLATION IA ftEPAfR/ADDITION l I DESTRUCTION t l (No septic systern permitted if public isew&r is <br /> available wtttttn 200 feet.) <br /> Installation will serve:. Residence_ Commercial.,,.,. 'tither <br /> Number.of living unita: Number of badroori7s C) <br /> Character of soil tn:g depth of 3 feet: VVatertable depth 0 <br /> SEPTIC TANK 17.: `Type/Mfg . Capacity— Nd'. ompartmmrits <br /> PKG.,:TREATME14T PLT.0 Method of Disposal , <br /> Distance to,nearest: Well Foundation Property Line ' <br /> LEACHING LINE 0 No.& Length of lines Total length/size <br /> FILTER BED: 0. :Distance'to.nearest:. Well Foundation Property Line <br /> .. <br /> SEEPAGE PiTS. 1,1 depth Size Number <br /> SUMPS LI Distance to-nearest: Watt Foundation Pronerty Line <br /> DISPOSAL PONDS El <br /> I hereby certify that 1 have prepared this application and::that the work will W done in accordance with San Joaquin county.,ordinanccs,state:ktws,:` <br /> rules and regulations of the San Joaquin Local Health Diktrict. <br /> Home owner:or licensed agent's signature certifies the following:""1 certify that in the performance of the work for which this permit is issued;I shalt not t <br /> employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature <br /> certifies the following:"I certifV that in.the performance of the work for which this:permit is issued,I shall vrnploy persons subject to workman:s.cotnperisa- <br /> tion taws of Calrtotnia."" <br /> The applicant must call for all M4uirecI inspectians:.;L"'omplate drawing on reverse side, f <br /> Signed . Title: eCl_f:cn1. ;I [ <br /> tag ,? IS�2�nnL . Tie. <br /> F't�gT �— <br /> W'3liattt G T aC R DEPARTIIAENT'USE ONLY <br /> PA ccepttid:byr :Area.: <br /> Pit of Grout fns ction b peby:, tJate:: <br /> Oe Y Date Final Inspection. <br /> Additional Comments: . <br /> ©Stk 466-6781 0 Lodi 369-3621 Cl Manteca. 823=7104 0 Tracy 835 6386: <br /> Applicant - Return all copies to:irrmeonmental Health Permit/Services 1601 E. Hazelton Ave., P.O.Box 2009, Stk.,.CA 9=1 <br /> PEE AMOUNT DUAMOUNT REMITTED RECEIVED BY, DATE PERMI?':NO.. <br /> INFO .: A Stt <br /> EN T3.24(REV.t1itS1 �r , <br /> r ,irf 74)8 3»?. .� `^ <br />