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\�[ APPLICATION FOR PERMIT ` ,0 �'1 \4SAN JOAQUIN LOCAL HEALTH DISTRICT R�GE1 1601 E. HAZELTON AVE., STOCKTON, CAU �Q �pJ , �� Telephone (209) 466-6781 \ � PERMIT EXPIRES TYEAR FROM DATE ISSUED NQv �A�\Atp�N RlQRQN �' (Complete in Triplicate) � � A lication hereby made to the San Joaquin Local Health District for a permit to construct andlor install the work hereirf application is � � cribed. This 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 Joaquin Local Health District. Job Address 2500 West Lodi Avenue City Lodi Lot Size Ri ght of W—ay PM Owner's Name Applied G@OSyStemS Address 4191–E Power Inn Road a "one – Contractor Spectrum Drilling Address 2825 E. No. 512268 Phone 209-465-871, TYPE OF WELL/PUMP: NEW WELL (R WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES 90, DISPOSAL FLD. _– PROP. LINE 20' FOUNDATION 50' AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casin ❑ industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation $" g ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Schd 40 PVC Specifications ❑ Public X Other monitorgelta Depth of Grout Seal 40' Type of Grout neat Cement Qn . I I Irrigation __.Appfox. Depth l I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter 2'r Sealing Material (top 501 Neat Cement Depth 65' _ Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION (I REPAIRIADDITION i I DESTRUCTION I i lNo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence— Commercial_ Other 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 PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. ✓3, Length of lines Total length/size r FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size _ Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 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," SAN JOAQUIN LOCAL HEALTH DISTRICT The applicant ust call for all required inspections, Complete drawing on reverse side. ENV(Ral+MENTAL HEALTH DIVISION Signed X Title `E'7F° ° abate 4Fw /88 FOR DEPARTMENT USE ONLY Application Accepted by Data Area Pit or Grout Inspection by Date�. Final Inspection by Date �`� Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca a23-7104 EJ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk_ CA 95291 FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO ♦ EH 13-24 MEV.I/M5) �g3 -' EH 14-28