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�x APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEILTON 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 compli nce 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 55 East Harney Lane City Lodi Lot Size PM Owner's Name City of Lodi Address 221. West Pine Phone Contractor Beyl ik Drilling, Inc.Address 3429 Longview Dr. License No. 306291 Phone 916 485-0792 TYPE OF WELLIPUMP: NEW WELL ❑ WELL REPLACEMENT ❑, DESTRUCTION IN PUMP INSTALLATION C] SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK n a SEWER LINES n/a DISPOSAL FLO. PROP. LINE n a FOUNDAI'ION AGRICULTURE WELL n a OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing C Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications M Public n Other n Delta Depth of Grout Seal Type of Grout _ I I Irrigation --Approx. Depth I I Eastern Surface Seal Installed by _ Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter 8`r Sealing Material (top 501 neat cemen Depth 547 t Filler Material (Below 501 gravel '-TYPE OF SEPTIC WORK: NEW INSTALLATION I') REPAIR/ADDITION l I DESTRUCTION I i (No septic system permitted if public sewer is . available within 2DO feet.) Installation will seine: Residence— Commercial_ Other ,R Number of living units: Number of bedrooms 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 Distance to nearest: Well Foundation Property Line LEACHING LINE CI No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I De6th Size Number 1 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 required inspections. Complete drawing on reverse side. Project Manager Date: June 8, 1989 . signed x 3 Title: David S. Bardsley FOP DEPART NT USE ONLY Application Accepted byT. Date 2 Area — Pit or Grout Inspection byA, ::� DateFT,?� nspection by + Datte Additional Comments: 's ' r+l, `fvl ❑ Stk 466-6781 ❑ Lodi 369-3621 LlMa eco 823-7104 ❑ Tracy 835-6385 'Ile + Applicant - Return all co ies to: E vironmental IJealth Permit/, ervic s 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 9520, �,lAf��✓`f1F��gAE�� /'c /%f��,1" � •,,��' ,�`—!; l .�'i�1'f�.�-- ��s+ �j��lc� FEE AMOUNT DUE AMOUNT REMITTEDK 41RECEIVED BY DATE PERMIT NO. [tom] 'H INFO 13-21(REV.tike)