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to '. 0>aSZN� APPLICATION FOR PERMIT - SAN JOAQUIN LOCAL HEALTH DISTRICTf AY "r 1p�P ,� 1601 E. I-IAZELTON AVE., STOCKTON, s A R CEIVE� 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 wortation is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and the FCIes,and ReP��Joaquin q tl+ Local Health District. 3T3tso� wL7zuTt� �� . Right of { Job Address 21-540 r;e s , _ s e., City Lodi Lot Size Wa ., PM Owner's Name Applied Geo Systems Address 4191—E Power Inn Road, Sacrame�,g�e"916-452-2901 Contractor S ectrum Dri11in 'Address 282 5 E Myr t I e S t S t n kiteme No. 5 122 68 __Phone - TYPE OF WELL/PUMP: NEW WELL R WELL REPLACEMENT ❑ DESTRUCTION ❑ ; PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ i DISTANCE TO NEAREST: SEPTIC TANK -- SEWER LINES ' 90' DISPOSAL FLD. PROP. LINE 20' FOUNDATION _L0L_ AGRICULTURE WELL OTHER WELL PITS/SUMPS __w__ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS - ElIndustrial 0 Open Bottom F] Manteca Dia. of Well Excavation Dia. of Well Casing 211 171 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Schd 40 PVC Specifications (I Public L4tOther monitor ❑ Delta Depth of Grout Seal ' Type of Grout neat cement I Irrigation µy 70.-Approx. Depth l I Eastern f Surface Seal Installed by - Repair Work Done ❑ Type of Pump H.P. State Work Done _ Weil Destruction ❑ Well Diameter 2rr Sealing Material (top 50') Neat cement Depth 65 r Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I] 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 Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK N ❑ Type/Mfg Capacity No. Compartments i 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 Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line I 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, an 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,:rH ® f'ioCll3liV �t��"�r�'' gTILe1rLT tion laws of California." kW ® `Rf��lNl3�IN �T4sALrI� EALTH DIV1SlQl�! The applica must call for all required inspections. Complete drawing on reverse side. 0%113tib f arty Marcus Title: Project GeologistSPE1 � �8 Signed x * FOR DEPARTMENT USE ONLY �� -89Application Accepted by Date Area Pit or Grout Inspection by d✓' " - Date v Final Inspection by i � � Data Lof Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 O Tracy 835-6385 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 K RECEIVED BY DATE PERMIT'NO. INFO �s a-EH 13-24(REV.r/K5) S ! �t e7 � �— .�� S9 EH 14-29