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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT a 1601 E. HAZE TON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 1 (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 Ryles and Regulations of the San Joaquin Local Health District, Job Address Lower Sacramento Rd. & elm. St.' City Lodi Lot Size PM r 221 West Pine St.' 209 Owner's Name City of Lodi.. Address -Lodit Ca. 95241-1910334-5634 Phone 8650 E. Lacey Blvd. 2(]9 Contractor Myers Bros. Inc, Address Hanford, Ca, 93230 License No. 280310 Phone582-9031 TYPE OF WELL/PUMP: NEW WELL ® WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE n FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE J TYPE-0 F WELL '- PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation. .!--32T1.,;_ Dia. of Well Casing 2011ID ❑ Domestic/Private 9 Gravel Pack 0 Tracy Type of Casing st el Specifications Ja Public ❑ Other ❑ Delta Depth of Grout Seal t Type of Grout Cement ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by or Repair Work pone ❑ Type of PumpH.P. State Work Dane Well Destruction ❑ Well Diameter Sealing Material Stop 50'1 cement _ `T Depth Filler Material (Below 50') QraVel Pack 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 Y Number of living units: Number of bedrooms : r 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 F Distance to nearest:'_' Well Foundation Property Line I x LEACHING LINE ❑ No. & Length of lines Total length/size i 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`••f 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. M ers Bros. Inc, 1 Signed X All Title: Contaller Date: 3/12/85 FOR DEPARTMENT USE ONLY } Applicatio ccepted by J141 Date -/�-- � Area �/ t Pit or L. spection by Date Final Inspection by-7Date Additional Comments: - - ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 8x3-7104'— ,:❑ Tracy` 6315,6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE CK 0 INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT`tJO. + EN13-24(REV. /a 5) - EH 14-26