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f . APPLICATION FOR PERMIT N`JOAQUIN LOCAL HEALTH DISTRICT F 601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (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 Rules and Regulations of the San Joaquin Local Health District. 11793 N. Micke Grove Road Lodi Job Address City Lot Size PM San Joaquin County Historical Museum 368-9154 Owner's Name Address Phone Contractor Clark Well Address 2024 E Charter Way License No_ 371568 Phone 462--7676 TYPE OF WELL/PUMP: NEW WELL 0 WELL REPLACEMENT ❑ DESTRUCTION ❑ y PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANKj-300 r SEWER LINES DISPOSAL FLD. PROP. LINE gn f FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS El Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation tt Dia. of Well Casing it "Domestic/Private XN Gravel Pack ❑ Tracy Type of Casing 5 tee Specifications • 109 w ❑ Public ❑ Other ❑ Delta Depth of Grout Seal 50, Type of Grout 9 sack \\ ❑ irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by Museum Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) r Installation will serve: Residence— Commercial 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 ❑ 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: "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 card f5a-71rilthe performanc of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." The applicaptf t c fa all q r in plete drawing on reverse side. Signed Title:drilling Engineer Date: 29 Jan 1987 FOR DEPARTMENT USE ONLY Application Acceptedb Date q Area Pit or Grout Inspection y Date Final Inspection by Date A 4 Additional Comments: -- - - ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 8354M5 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 CK RECEIVED BY DATE PERMIT'NO. INFO CASH `} + EH 13-21(REV. les) EH 1426 �vC —al47 �7 /7/ /` �.J