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APPLICATION FOR PERMIT MENT E0 JOAQUIN LOCAL HEALTH DIS TRI 1601 E. HAZEL T ON AVE., STOCKTON, C r ��'• `�,.f� k w>'� Telephone 12091 466-6781 r•z. PERMIT EXPIRES 1 YEAR FROM DATE ISSUED pjo (Complete in Triplicate) QNM ��y[ ApRg&t P heieby made to the San Joaquin Local Health District for a permit to construct and/or install the work hereiNabed. This application is grade in compliance with San Judquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District Job Address 2500 West Lodi Avenue _ City Lodi Lot Size Ri ht of Way PM Owner's Name Applied GeoSystems Address 4191—E Power Inn Road, Sacramept�eone 916-452-2901 Contractor Spectrum Urilling__Address 2825 E. Myrtle St. Stocll,itdme No._512268 Pnone 209-465-871 TYPE OF WELL/PUMP: NEW WELL LR WELL REPLACEMENT I 1 DESTRUCTION [ i PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST; SEPTIC TANK -- SEWER LINES 90, —_ DISPOSAL FLD. --- PROP. LINE 20' T FOUNDATION 50' AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS I ! Industrial Ll Open Bottom ❑ Manteca Dia. of Well Excavation 811 -_ Dia. of Well Casing Zr _ f 1 Domestic/Private ❑ Gravel Pack [ } Tracy Type of Casing Schd 40 PVC Specifications 'l Public Dpi Other monitoriTlIgelta Depth of Grout Seal 40' Type of Grout neat Ct'ment Irrigation Approx. Depth I 1 Eastern Surface Seal Installed by Repair Work Dune I] Type of Pump H.P, State Work Done } Well Destruction I 1 Well Diameter _2rr c— _ Sealing Material {top 50'I Neal en_ti Depth 6 t Filler Material [Below 501 TYPE OF SEPTIC WORK, NEW INSTALLATION I I REPAIR/ADDITION I 1 DESTRUCTION I I [No se ticsystem permitted if public sewer rs {ti available within 200 Net.I Installation will serve: Residence _ Commercial Other _ C Number of raving units: __ Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK f] Type/Mfg Capacity No. Compartments PKG, TREATMENT PLT. CI Method of Disposal Distance to nearest: Well Foundation _- Property Line LEACHING LINE I 1 No. & Length of lines Total length/size---- FILTER ength/size —_FILTER BED I I Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS I i Distance to nearest: Well Foundation Property Line _ r 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 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 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." 1 r. ,w--, r-.,1 r ,- ; The applicant ust call for all required inspections. Complete drawing on reverse side. --�„ - t;, ;-I;ql •_i r.Fj ; - ;1';i ;1 f L. Signed X_ L rL� �itla: p_LQ eCt GP_QLO i r $ 6_� t3ate: 11•/'F3/88 FOR DEPARTMENT USE ONLY Application Accepted by Date I !J9 Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: fL3 Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED }{ HECEIVED BY DATE PERMIT N0. s EH 1324 IREV.1, EH 1128 f'�r-`