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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telepho6e (209) 465-6781 PERMIT EXPIRES TYEAR FROM DATE ISSUED (Complete in Triplicate) A 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' sf Local Health District. ` Joh Addre1 8 8 4 6} N. Hwy 9,9 �� City Lodi Lot Size PM s�� t5 h I NVIV Victor Fine Foods same 464 1393 Owner's Name Address Phone Clark Well 2024 East Charter W 371560 462-7676 Contractor Addressense No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION EX SYSTEM REPAIR ❑ OTHER ❑ t DISTANCE TO NEAREST: SEPTIC TANK +15 0 r SEWER LINES DISPOSAL FLD. r PROP. LINE 25# r FOUNDATION AGRICULTURE WELL OTHER WELL 100 PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing l ❑ Domestic/Private ❑"Gravel Pack ❑ Tracy Type of Casing Specifications I'1 Public ❑ Other Ll Delta Depth of Grout Seal Type of Grout f I I Irrigation T-Approx. Depth l I Eastern Surface Seal Installed by _ Repair Work Done ❑ Type of Pump Turbine H.P. 50 State Work Done _7_nstal I OQ Well Destruction ❑ Well Diameter Sealing Material (top 50') q� Depth Filler Material (Below 501 h� TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR/ADDITION I I DESTRUCTION l 1 (No septic system permitted if public sewer is available within 200 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 f LT. ❑ Method of Disposal Distance to nearest: Well Foundation Property.Line t, LEACHING LINE ❑ No. & Length of lines Total length/size 3 FILTER BED ❑ Distance to nearest: Well Foundation Property Line t SEEPAGE PITS I 1 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 he done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health Di§trict. # 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 the performance of he work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of Cal' rni . The applica s all a qu" d i ro C plate drawing on reverse side. Signed Title: YP Date: 16 Marc-h J 989 FOR PARTMENT USE ONLY Application Accepted by Date ^`�^ Area v j r Pit or Grout Inspection by Date Fina) Inspection by Date d- 3 Additional Comments: ❑ Stk 466-6781 ❑ Lodi ' 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 t Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.D. Box 2009, Stk., CA 95201 FEE I INFO AMOUNT DUE AMhO�UNfT�REMITTED CASH RECEIVED BY DATEf��, PERMIT'NO. Y ♦.EH 13-24 01 EV.r i n 5) CJI aL ` f J�° (r��r_s..�/ 7 EH 14-20 1 (� l`