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APPLICATION FOR PERMIT 3, SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ;F• - � (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 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 Roger Raymond-13021 N Lower Sac Rd,Cis Lodi Lot Size 5 acres PM 7774 Owner's Name Roger Raymond Address ,1 3021 Lower Sac $d Phone 68- Clark Well & Equip , 371560 462-5597 Contractor's Name License No. Phone o TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT!E DESTRUCTION ❑ PUMP INSTALLATION ❑ ---SYSTEM-REPAIR'❑ OTHER ❑ oo DISTANCE TO NEAREST: SEPTIC TANK � SEWER LINES �O6 -- DISPOSAL FLD:;° PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL 30 f t PITS/SUMPS___ INTENDED USETYPE OF WELL ~ PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑_Open Bottom _❑ Manteca pia._of Well Excavation " -Dia.-of Well " Domestic/Private Gravel Pack ❑ Tracy ��Type of Casing S to e l Specifications • 10 9 ED Public ❑ Other ❑ Delta .Depth-of Grout Seal 50 f t, rType of Grout Sack m ❑ Irrigation _- Approx. Depth ❑-Eastern --5urface•Seal Installed by Clark Well' Repair Work Done ❑ Type of Pump slb�' H.P._ �2 State Work Done install j Well Destruction ❑ Well Diameter Sealing Material Itop 501 Depth Filler Material {Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system emitted if public sewer is avaInstallation will serve: Residence— Commercial 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 I Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Dlstance:to"nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDSElI 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-isAssued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." Contractors 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.'; J r f' The applican cal! r aill• ire' s cti wing on reverse-side.' Signed - _Title: Contractor Date: 3 Jan �, . 8 FO DEPARTMENT USE ONLY 4 1�` _ Z Date res Area G /2 k Application Accepted by Date^/ Pit or Grout spection by Date Final Inspection by Additional Comm-ants: ❑ Stk 4864781 ❑ Lodi 1 ❑ Manteca 823-7104 ❑ Tracy Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 i FEE AMOUNT'DUE' AMOUNT REMITTED CASH RECEIVED BY_ _ DATE PERMIT NO. INFO + EH 13-24(REV.10183) 3 /—p�✓U y 0 EH 14-28