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APPLICATION FOR PERMIT j SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone 1209) 6-6781 PERMIT EXPIRES 1 YEAR FROM! DATE ISSUED (Complete in Tri licate) 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 Sari Joaquin County Ordinance No.549 for sewage 6r No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address lW E�Iit Fettl= IBM ity Lodi Lot Size PM Owner's Name AFD ' Address P.O. i3mc 5811 5bn Matm Phone 415--571-2434 1 Contractor_ ,,] Address €cense No, 59K545 Phone TYPE OF WELL/PUMP: NEW WELL N WELL REPLACt MENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK >50 ft SEWER LINES >50 ft DISPOSAL FLD. >50' PROP. LINE M FOUNDATION �10t AGRICULTURE WELL . � OTHER WELL L5Wr PITSISUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS (=1 Industrial El Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Orr {-1 Domestic/Private ( Gravel Pack ❑ Tracy Type of Casing PCU Specifications Fl Public n Other 11 Delta Depth of Grout Seat $y Type of Groutnt I I Irrigation Approx. Depth I Eastern Surface Se•I Installed by ck-t l lir- Repair Work Done ❑ Type of Pump IA H.P. State Work Done Well Destruction ❑ Wet! biometer Orr Sealing Material (top 'I _ bE3'tL�Ct71t�G>�"It pi= � EdlactiMDepth 251 Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I O STRUCT p ' Ttableepth tted if public sewer is Q ail I ! Installation will serve: Residence_ Commercial_ Other O(C is Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments n l PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines 'Total length/size I FILTER BED ❑ Distance to nearest: Well Foundation Property Line tl SEEPAGE PITS 11 Depth Size _ Number SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ i 1 I hereby certify that I have prepared this application and that the work wilt be done in accordance with San Joaquin cHunty 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: "1 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." The applicant m II Tor all ►e Iced inspec tons. Complete drawing on reverse ide. i i Signed X Title: Date: t� r ELCim K. FHds FORD TMENT ONLY Application Accepted by Date 17'AF11 Pit or Grout Inspection bye— Date Inspection by�� Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ T acy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Ha, elton Ave., P.O. Box 2009, Stk., CA 95201FEE i INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED By DATE PERMIT'NO. fH $374InEv.1ix51U [• c� �371 3Y EH 1CM