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APPLICATION FOR PERMIT N JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON 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 -J made in compliance with San Joaquin County Ordinance,No.549 for sewage or No. 1662 for,well/pump and the Rules and Regulations of the San Joaquin r Local Health District. 5400 East Harney Lane 1city Lodi Lot Size 110 acre PM Job Address ran re ss Color Spot Address same Phone Owner's Name 805 Consultant:Staal, Gardner & Dunner inC, Fir St. License No.�Ot A Phone — i Htfiik Kor Address.l7._ 1, 1y TYPE OFWELL/PUMP: NEW WELL ❑ WELL REPLACEMENT.:❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR.❑ OTHER q Soil Vapor Survey DISTANCE TO NEAREST: SEPTIC TANK 100t SEWER LINES - !' DISPOSAL FLD. PROP. LINE3Q4111 FOUNDATION,100'+ AGRICULTURE WELL 200_ OTHER WELL 3 cnr .- PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing none ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation KI Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing none Specifications CI Public ❑ Other n Delta Depth of Grout Sealenti rp int-je lType of Grout youlC-la-j�—. - I I Irrigation _—.Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done 11Type of Pump H,P. State Work Done_ volclay Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 50'1 -- TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR/ADDITION I I DESTRUCTION I I (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 - O 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 FoundationProperty Line f SEEPAGE PITS I I Depth Size - Number SUMPS - Cl 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, rules and regulations of the San Joaquin Local Health Di3trlct. 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 subcontracting signature certifies the following: "I certify 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 California." i The applicant must 0caallll for all required inspections. Complete drawing on reverse side. Signed A^^"'""' ` �eo% Title: Rpgi ctered°r Pol noic�._.o t yZ 1K Date: J`/3/e/C� baa ar ner joi unne Ina. by William�CT aCy/� R DEPARTMENT USE ONLY Application Accepted by �(�,f/�""��"'�D� "�'�� Date 8� Area Pit or Grout Inspection by /, /l � Date Final Inspection by Date Additional Comments: /.�rrC.�V C.f99u-1tX.� ❑ Stk 466-6761 ❑ Lodi 369-3621 ❑ Manteca 623-7109 111 Tracy , 635-6365 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 9H RECEIVED BY DATE PERMIT NO. INFO . EH 13341REV.1/x5) 3S �/ ,3 O ,), _ S7 EH 14 26