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A .KATION FOR PERMIT OAHAZELTOaUIN LOCAL HEALTH DISTRICT CA 9� SAN N AVE., STOCKTON 1� 1601 E. 466-6781 L Telephone 12091 PATE ISSUED SAN �dAQ,J�N C"moc, 1 YEAR FROM LAN. Ir;, V1510N PUJ30C��AL MEP`• �'i PERMIT EXPIRES This application is tete in TripljCate) N�4�WaSlerein described. (Comp Regulations of the San Joaquin for a permit to construct and/or ina the Rules and Reg uin Local Health District sewage or No. 1862 for well/pump See attached Application is hereby made to the County Ordinance No. Site maP PM �— made in compliance with San Joaquinj,pol Lot Size 1943 City (209)333- Local Health Distriictt.. N• Main Street Lodi r Cp, 95240 phone 112 S. Mai.n St, - Job Address JA & P InVestiTents Address Drive hone ,E 2120 B11m�nfeld /� License N ❑ owner's Name C,4 �ng 7R � Address WELL REPLACEMENT ❑ T R L — PROP. LINE Contractor�� NEW WELL ❑ SYSTEM REPAIR DISP PITS/SUMPS TYPE OF WELLIPUMP: PUMP INSTALLATION ❑ SEWER LINES OTHER WELL SEPTIC TANK �— AGRICULTURE WELL _� DISTANCE TO NEAREST: Dia of Well Casing FOUNDATION � AREA CONSTRUCTION SPECIFICATIONS WELL PROBLEM Dia. of Well Excavation Chi Specifications TYPE OF INTENDED USE C3 Manteca Type of Casing Type of Grout ❑ Open Bottom ❑ Tracy ❑ Industrial Depth of Grout Sea( \`\ ❑ Gravel Pack n Delta pe tr- Q 66 ❑ Domestic/Private Surface Seal Installed by one ren 6�Other Depth ( ( Eastern State Work D (1 Public —APProx- DeP H.P. I I I,igation (] Type of Pump Sealing Material (top 50') tic system permitted if public sewer is Repair Work Done feet.) Well Diameter Filler Material IBelow available within 200 Well Destruction ❑ Depth EpQ1R/ADDITION 1 1 DESTRUCTION l I lNo sap � NEW INSTALLATION I I R TYPE OF SEPTIC WORK: Commercial— OtherWater table depth — Residence — Installation will serve: Number of bedrooms No. Compartments Number of living units: capacity------- Me depth of 3 feet: Line of Disposal Character of soil to a O Type/Mfg property Line SEPTIC TANK TREATMENT Foundation TMENT PLT.❑ Well PKG. Distance to nearest: Total length/size Property Line �— ❑ No. $ Length of lines Well Foundation—� ^ LEACHING LINE ❑ Distance to nearest: Number FILTER BED property Line Size�— ( I Depth Well Foundation_� state laws, and uin county ordinances, SEEPAGE PITS L Distance to nearest: I shall not SUMPS permit is issued, signature oaq OSAL PONDS ❑ lication and that the work will be done in accordance with San or sub-contracting 9 DISP this app rformance of the work for which this p ensa- certify that I have prepared ••l certify that in the pe arsons subject to workman's comp I hereby ensation laws of California-lemploy Ptor s hiring i rules and reg nature certifies the workman's comp permit is issued, regulations of the San Joaquin Local Health District. Home owner or licensed agent's sig OM any p that in the performance of the work for which this p ` Z arson in su1 certify as to become subj Complete drawing on reverse side. Date: certifies the following:� Comp Drilling tion laws of California." inspections. rj'p11t0 lican must call for all required The apP `SGS Title: D TMENT USE ONLY rea Signed Date Z.—Z. —� Date Accepted by Final Inspection by Application Da i �, 7 S Pit or Grout Inspection by 835.6385 e 823-7104 Tracy Bo" 2009, Stk., CA 95201 Additional 6781 Comments: ❑ Lodi 369-3621 ❑ Manteca Hazelton Ave., p•0 fes to: Environmental Health Permit/Services 1601 PERMIT'NO. ❑ Stk DATE Applicant - Return all cop CK RECEIVED 8Y FEE AMOUNT DUE AMOUNT REMITTED CASH INFO . EH 13-24 IREV. i n 51 rm 14-26