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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT PAYMENT 1801 E. HAZE T ON AVE., STOCKTON, CA RECEIVED Telephone (209) 466-6781 v f . 804 1991 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 1}lN CC}t�N�Y (Complete in Triplicate) PUBLIC H�HEAL' �+I f s nnnn�� NTAI.HI:Ai,ts,l�lViSIQN Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or inst��'1kbf erein 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. See attached 40 N. Main Street Lodi site map Job Address City Lot Size PM Owner's Name M & P Investments Address 112 S. Main St, Lodi, CA- Phone 95240 (209)333-1943 r,,4n*_- cf-AI k 2120 Blumenfeld Drive Contractor � �lg Address SaeramentQ. CA License No.584907_ _ __Phone — TYPE OF WE NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER Xl DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. POOP. 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 1 -9 i ncheq Oia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ('l Public X Other ❑ Delta Depth of Grout Seal Type of Grout CemeTlt _ i I Irrigation _Approx. Depth I 1 Eastern Surface Seal Installed by _ Repair Work Done ❑ Type of Pump H.P. State Work Done C)M penatrat On Well Destruction 171Well Diameter Sealing Material (top 501 and sa=ling Depth fin feet Filler Material (Below 501 (See work plan) v TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION l I DESTRUCTION l 1 (No septic system permitted if public sewer is available within 2110 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 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 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 applican must tail for all required inspections. Complete drawing on reverse side. Signed _ ! 42Y Title: Tonto Drilling _ Date: 1 Z g DgPAATMENT USE ONLY Application Accepted by Date rea Pit or Grout Inspection by D`a Final Inspection by Date 2.ZD Additional Comments: � -i I—*- ., ✓I.b �- }yl .', ❑ 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 INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. + EH 13-24(REV. EH 14-28