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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT r 1601 E. HAZEL T ON AVE., STOCKTON, CA ' Telephone (209) 466-6781 PERMIT EXPIRES TYEAR'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 t 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 JoaquinM Local He'�r Ith District. y 0_579"`- 2—Coo "`��1 fKettlerrtanCai elLakeshore Dr.. Job Address, City - Lodi Lot size 3001 X 30n, PM l Owner's Name State Farm I nsurance Co. 1 Address CIO CaStillOCO.,, Phoenix; AZ Phone602-231-9000 l F� ContractorBSK S Associates4 Address5729-F Sonoma Dr. PleasaDMI?e No.490942 Phone(415) 462-40 0 TYPE OF WELL/PUMP: !NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ So1-1--Borings PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER N r �Compar don Testi DISTANCE TO NEAREST: SEPTIC TANK —"— �{HhfES a 50 DISPOSAL FLD. — PR P. LIN g) FOUNDATION 501' AGRICULTURE WELL — OTHER WELD — :PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS i �T ❑e)industrial ❑ Open Bottom I] Manteca _. r Dia- of Well Excavation Dia. of Well Casing 8 IS)- ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type e of CasingHol IoW Stp em Specifications � N�A i`l Public 1-1Other 171 Delta Depth of Grout Seal 20t Type of Grout Cement Grou i d Irrigation --Approx. Depth I I Eastern Surface Seal installed by Repair Work Done 0 Type of Pump H.P. z -State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material IBelow 501 TYPE OF SEPTIC WORK: NEW INSTALLATION i 1 'REPAIR/ADDITION f.I -DESTRUCTION-11"(Nt5-septic system permitted if public sewer is available within 200 feet.! Installation will serve: Residence Commercial— Other N./A Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments f PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size N IA FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size ' Number N/A SUMPS L� 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, anf rules and regulations of the San JoaquinLocal Health District: s t 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 shalt noemploy any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signaturcertifies 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 compensation laws of California." The applicant m ca for a fired i ' ,4peptions. Co plate drawing on reverse side. m Signed X j// T;tle; Mana er - Geotech.. Services Date: 4-5-89 Alex Y. Eskanclar' FORD PARTMENT USE ONLY Application Accepted by Data Area �a / �Pit or rout�Inspection by Date AkFinal Inspection by Date Additional Comments: j ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 l Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 AMOUNT DUE AMOUNT REMITTED ItE � RECEIVED BY DATE PERMIT'NO. +,EH 1324 tItEV.I/n 51 EH 14-2B f