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APPLICATION-FOR PERMIT 4, v SAN JOAaUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA APR Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ENVIROMENTAL HEALTH � (Complete in Triplicate) FERMIT/SERVICES, 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 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. Job Address 15190 N. Locust Free Rde City Lodi Lot size 91. acres PM Owner's Name Randy COX Address 15190 N. Locust Tree Rd. Phone 339-1190 Lodi,Ca. Contractor's NameWoods Well Drillin License No. 282866 Phone 745-2407 � TYPE OF WELL/PUMP: NEW WELLX WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLALON 131 SYSTEM REPAIR El OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK loot SEWER LINES 100 DISPOSAL FLD. PROP. LINE 201 FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Ll Industrial SI Open Bottom 11 Manteca Dia. of Well Excavation rr Dia. of Well Casing rr r X Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing At 12 Specifications (1,cenar ❑ Public ❑ Other ❑ Delta Depth of Grout Seal 501 Type of Grout qa ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by i Repair Work'Done ❑ Type of Pump H,P. State Work Dane Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No 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 SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments 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 ❑ 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 ball for all required inspections. Complete drawing on reverse side. - Signed Title: Contractor Date: 4-11-87 f FOR DEPARTMENT USE ONLY Application Accepted by Date —�z�`�2 Area G Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: ❑ 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 r K H RECEIVED BY DATE IT" INFO lie + EH 13-24[REV.101831. / /� � EH 1426