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'APPLICAT(QN FOR'PERMIT i `r SAN' IOA[lUl'N LOCAL HEALTH MSTRICT 1601 �E. F#AZELTON AVE.,;STOCICTON; CA r. ti Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is heieby made to the San Joaquin Local.Health District fora permit to construct and/or install the work herein described. This application is made in compliance with.Sari Joaquin County Ordinance No. 548 for sewageor No..1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. between Che>rr & U•ine, East- Of Washington Lotti 900 scj ft Job Address, City Lot Size PM f City of Lodi' 221 West Pine 334-5634 Owner's Name Address Phone Contractor ClarkWell Address 2024 Cast Charter- License No.a.715_6Q Phone 462-7676 TYPE OF WELL/PUMP:,, NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION A 2 we-LIS PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTICTANK SEWER'LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS'' INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial >XI Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Q Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications 17 Public FI Other ❑ Delta Depth of Grout Seal Type of Grout _ I I Irrigation �-Approx. Depil G l I Eastern Surface Sea] Installed by Repair Work Done . ❑ . Type of Pump /� H.P. State Work Done_ Well Destruction Well Diameter:l.l1 ! Sealing.Material (top 501 9 8br--IL m.1 X Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION 11, REPAIR/ADDITION I I DESTRUCTION I 1 INo septic system permitted if public sewer is available within 200 feet.) I , 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 SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments Vi 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 i I Depth Size Number SUMPS Ll 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 laand rules and regulations of the San Joaquin Local Health District. 41 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 man to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the following: "i ce that in ormance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of Californ' The applicant call r q r i / C'mplete drawing on reverse side. r Signed x / r - Title:UP Clark Well Date: 28 Oct 1987 DEPART QOT USE Ya Application Accepted by Date a Area / D Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: b oF- ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 83 5 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.D. Box 2009, StC, CA 95201 INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. + EH 13-24 IREV.I/K 5) 0 I� vn EH 14-26