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APPLICATION OR PERMIT' C(,�u� G / SAN JOAQUIN LOCAL HEALTH DISTRICT '- 1601 E. HAZELTON AVE., STOCKTON, CA °`� .y ' Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM. DATE ISSUED HID 121989 (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work lierein,4s � is application is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and the Rules arid-�ei� tkn o the tan Joaquin Local Health District. Job Address 12637 N. Hwy. 99 City Lodi Lot Size PM Owner's Name Charles Reed — Address 12637 N. Hwy, 99 Phone 17754 N. Hwy. 88 Contractor Address License No.309431 Phone J TYPE OF WELL/PUMP: NEW WELL 0 WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION XX SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED OSE' TYPE'OF WEEL° ' -- RORLEWAREA --CONSTRUC-110N-SPECIFIC;MONIS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications t"1 Public Cl Other 17 Delta Depth of Grout Seal Type of Grout I Irrigation _.Approx. Depth I l Eastern Surface Seal Installed by _ Repair Work Done ❑ Type of Pump Sllh_ H.P. 2 State Work DondMpIaCP(I Old pump Wl new Well Destruction ❑ Well Diameter Sealing Material Itop 50') Depth Filler Material /Below 50') 1 TYPE OF SEPTIC WORK: NEW INSTALLATION f 1 REPAIR/ADDITION { I DESTRUCTION I 1 {No septic system permitted if public sewer is 1V P available within 200 feet.) Installation will serve: Residence_ Commercial— Other { ` Number of living units: Number of bedrooms J�7 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 c SEEPAGE PITS I I Depth Size Number � SUMPS Ll + Distance to nearest: Well Foundation Property Line 4) 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 nor as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the following: " y 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 CalifWa 'The applicant mull uired inspections. Complete drawing on reverse side. Signed X Title: Rkpr Date: 09/06/89 / /AFOR DEPARTMENT USE ONLY 21 Application Accepted by /,L!/��/ Data r� Area �7 Pit or Grout Inspection by Date Final Inspection b ��ice----�, Date1 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 VN FEE INFO AMOUNT DUE AMOUNT REMITTED CK 4 CASH RECEIVED BY DATE PERM IT'N�O.,.. �.EH 13.21(HEV.IiH5) EH 11-26 �5 _rho L\A-'�V.!