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APPLICATION FOR PERMIT '2 SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL i ON AVE., STOCKTON, CA Telephone (209) 466-6781... . E 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. Intersection of Extension of ane t e. Central Calif Traction Railroad Line Job Address City I O d J Lot Size 6 0! X 4011 PM City of Lodi Address box 3006 Lodi Phone 333-6706 Owner's Name Clark Well v 2024 E. Charter Way 371560 462--7676 Contractor Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ® Test Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. 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 Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public U 9ther Test ❑ Delta Depth of Grout Seal Type of Grout El Irrigation 48_Approx. Depth ❑ Eastern Surface Seal Installed by k ' Repair Work Done ❑ Type of Pump H.P. State Work Done j 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.) Installation will serve: Residence— Commercial_ Other F Number of living units: Y 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. ❑ E Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ 'No. &�Lenoth of-lines Total length/size FILTER BED ❑` Distance to nearest: Well Foundation Property Line 4 i SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line # DISPOSAL PONDS ❑ I 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, and I rules and regulations of the San Joaquin Local Health District. i I 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, shall not employ any-perso. ' suWras ome subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the foil i "1rformance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of li ni .'The applic t s 1ctions. Complete drawing on reverse side. ' Signed Title: VP—Clark Well Date: 2 0 July 1987 FOR DEPARTMENT USE ONLY q Application Accepted by 12V r Date { Area d Pit or Grout Inspection by Date Final Inspection by OAAA Date Additional Comments: I ❑ Stk 466-6781 IS Lodi 36.9-3621 U ❑ Manta623-71 ❑ Tracy 835- F Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Sik., CA 95201 c t PEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. INFO CASH t EH13-24 TREY. e 51 �� EH 14-26 llV��