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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR 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 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 2453 Stogy Creek Rd. city Galt Lot Size 2 SLC PM Owner's Name Cha,rleS Lake Address 15475 Moore Rd.LOds,CA• Phone 334-2101 Contractor's Name Woods Wehl Drilling,,,,, No. 282866 Phone 745-2407 TYPE OF WELL/PUMP: NEW WELL& WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLA ION]r SYSTEM REPAIR ❑ OTHER 11DISTANCE TO NEAREST: SEPTIC TANK 50 SEWER LINES 150DISPOSAL FLD. PROP. LINE 50 FOUNDATION AGRICULTURE-WEL��--OTHER WELL -7 PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFIC/TIONS 11Industrial 2Open Bottom F) Manteca Dia. of Well Excavation 44 Dia. of Well Casing tt 19 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Steed., Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal 501 Type of Grout per re ui emmt ❑ Irrigation 220-!—Approx. Depth ❑ Eastern Surface Seal Installed by woods Repair Work Done ❑ Type of Pump SUB, M.P. 3 State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50'] ^ Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) r � 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. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS C1 Depth Size Number SUMPS _ ❑ 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, 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." The applicant must call for all require inspections. Complete drawing on reverse side. _ Signed � i Title: Contractor Date: 9-30-86 FOR DEPARTMENT USE ONLY Application Accepted by Date _/_aff Area Pit or Grout inspection by Date to Final Inspection by oez Date ' Additional Comments: ❑ 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 AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT'NO. INFO + Er 14-24IREv.10i84l iib 12r ��7� 1 �V �10 IZS$ EH 14-28