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F� APPLICATION FOR PERMIT rr SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is heteby 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. 5400 East Harney Lane Lodi 110 acre Job AddressCity Lot Size PM ran reiss Owner's Name Color Spot Address same Phone Consultant:Staal, Gardner & Dunne, nc805 19*Xr'4igor Address . License No. Not A Phone653-5556 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER Ck Son Vapor Survey DISTANCE TO NEAREST: SEPTIC TANK 100± SEWER LINES DISPOSAL FLD. PROP. LINE3Q.�� FOUNDATION 100'+ AGRICULTURE WELL 2nn OTHER WELL r PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing none Kl Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing none Specifications Fl Public ❑ Other ❑ Delta Depth of Grout Sealers t•i re i n t e=a l Type of Grout ..v-o.1 c l n y I I Irrigation __Approx. Depth l 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 volcla Depth Filler Material iBelow 50') --- —_ TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I 1 iNo septic system permitted if public sewer is available within 200 feet.► Installation will serve: Residence_ Commercial— Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth 0 SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT, ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE 0 No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I 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, 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 required inspections. Complete drawing on reverse side. Signed X 6� � C ,y�✓I Title: Date: staal�dner &Dnney -Lnc. by William �C�Tac R DEPARTMENT USE ONLY p Application Accepted by /SyydAQ.x¢/ Date 4 Area Pit or Grout Inspection byD/Jate Final Inspection by Date Additional Comments: _ to&J.J fiA-A:!L"W OI � 5/4�reT fJ ❑ 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 FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO SH + EH 13-24(REV.t i y slIFjj EK 14-28 5A 1 JS_7