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! APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1'YEAR FROM DATE ISSUED o (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 f. made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and the e Rules and Regulations of the San Joaquin Local Health District. Job Address 12571. - Nor.th Mundy Roacd City Lodi Lot Size PIN - Owner's Name MARKZINDSETH Address 1,2571 N Mundy Road Phone 369-1958 # Contractor Clark Well .1—Address 202 • E Charter Way License No. 371560 Phone 4627676 TYPE OF WELL/PUMP: (NEW WELL L1WELL REPLACEMENT El DESTRUCTION El t " PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD- PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL ?ITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS , ........-D,"ustdaL.-...w—K.....,..,..-D-Open.B..ottom— l,.Manteca__ die.-,of Well-Excavation Dia of,Well CasinrJc „A ', EK Domestic/Private ❑ Gravel Pack El Tracy Type of Casing Specifications t is l-1 Public ❑ Other.,(! Cl Delta Depth of Grout Seal Type of Grout I I Irrigation. _.-Approx. Depth I I Eastern Surface Seal Installed by Owner _ ' Repair Work Done Cl Type df PU' Su ] H.P.9 2 State Work Done _Tnstalled T Well Destruction ❑ Well Diameter Sealing Material (top 501 t. Depth"1 Filler Material (Below 50') s ',TYPE OF SEPTIC WORK: NEW-INS- ALLATION [ I REPAIR/ADDITION I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) �linstalfation will serve: Residence'�— Commercial— Other ; Number of living units: CNufnber of bedrooms r Character of soil to a depth of 3'feet: Water table depth SEPTIC TANK ❑ Type/MfgCapacity No. Compartments PKG. TREATMENT PLT. LI y�Y Method of Disposal' rf { - Distance to nearest: We11 Foundation Property Line y LEACHING LINE ❑ No. & Length of lines ��"� �, Total length/size FILTER BED, ❑ Distance to nearest: Well 'foundation Property Line t t L SEEPAGE PITS I I Depths Size t Number SUMPS ❑ Distance to nearest: Well ,`Foundation ?Property Line 6 F DISPOSAL PONDS ❑ i- 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, ands, rules and regulations of the San Joaquin Local Health Di§trict. a t Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issue. I shall n�. employ an rson in such manner as'to becomes sect to workman's compensation laws of California Contractor's hiring or sub-contracting signature certifies th "lowing: " c ify that ink perform ce of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws o alifornia.' ,�_'; S y F I The applica ust call or I qui i s etiort mp19te.dr wing on reverse side. I` Sec--Tres 21 April 8 Signed X Title:+ Date: 9 FOR DEPARTMENT USE ONLY r Application Accepted by Date Area Pit or Grout Inspection by I Date Final Inspection by Date t Additional Comments: 0 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 CASH RECEIVED BY DATE PERMIT'NO. a.EH 13-24 IgEV.t/A 51 INFO 512 EH 14-29