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In `� r APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT PAYMENT 1601 E. HAZE T ON AVE., STOCKTON, CA RECEIVED Telephone (209) 466-6781 PERMIT EXPIRES T YEAR FROM DATE ISSUED MAY 0 4 1989 (Complete in Triplicate) SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or instalt4ylRGRMENMeWrMV"IVOIDkation is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1662 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address 18001 East Kettleman Lane City Lodi Lot Size 1 000 ftZ PM Owner's Name Pac-Tel Cellular Address 650 Howe Ave #800, Sac ,CA Phone 916-646-3773 Earthtec Ltd. 1830vVernonCSt9#77$ 408595 Contractor � Address License No. Phone 916-786-5162 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER]U test boring DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FL6. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation I a Dia. of Well Casing N/A ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications 11 Public FkOther test b ypg Depth of Grout Seal Exll_-depth Type of GroutF(i_WJbe11t nice I I Irrigation _MApprox. Depth ( I Eastern Surface Seal Installed by Repair Work Done L] Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material Itop 501 Depth Filler Material (Below 50') _ TYPE OF SEPTIC WORK: NEW INSTALLATION l 1 REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.► p`► Installation will serve: Residence_____ Commercial_ Other o Number of living units: Number of bedrooms U Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments r{� PKG. TREATMENT PLT. ❑ Method of Disposal r 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 - : ❑ 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. Signed X Title: Principal Con,si,j] cant Date: -May 3 , 1990 F R DEPARTMENT USE: ONLY / Q Applicati n Accepted by Date_ S.��d I�/ d Area Pit o Grou inspection by• Date r' Final Inspection bya> ,�;al i Additional Comments: "14 C-rDu+ iYy •1e O ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca -7104 ❑ Tracy 635-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 45201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. +.EH 14-24tREV.1iHSi ` O o ~1119 EH I4-28 s� � / S