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APPLICATION FOR PERMIT i SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE i ON 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. 1662 for welUpump and the Rules and Regulations of the San Joaquin j Local Health District. Job Address 12431 tOky Con1gy City LODI: Lot Size_ � aC PM Owner's Name J1114 HOGUE Address FIL100TJ ED Phone -»O-,r; Contracto►L+1TH GROSS Address]�Q BOX 178 _QQDB47T�[T -icense No. 37_7TH Phone i TYPE OF WELL/PUMP: NEW WELL,; WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION: SYSTEM REPAIR Ll OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK �� SEWER.LINES DISPOSAL FLD._ PROP. LINEca4_f P_et FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS ..� INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS X ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing 46 Domestic/Private -Mit,ravel Pack ❑ Tracy Type of Casing D-Ax Specifications {"l Public F Other F1 Delta Depth of Grout Seal Type of Grout I I Irrigation _..Approx. Depth ( I Eastern Surface Seal Installed byet_ E)%re _- _ Repair Work Done ❑ Type of Pump v111) H.P. 'f 4 /'l State Work Done_ Well Destruction ❑ Well Diameter Sealing Material (top 501 III Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION I] REPAIR/ADDITION I I DESTRUCTION 11'(No septic system permitted if public sewer is available within 200 feet-1 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 i I Depth Size Number SUMPS Cl 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 1 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, l shall employ persons subject to workman's compensa- tion laws of California." s The applicant must calired inspections. Complete drawing on reverse side. Signed X_ Title: 0WIMIR Date: --�J-►�3rs + • i FOR DEPARTMENT USE ONLY Application Accepted by Date 12— 7.94 Area Pit or Grout Inspection by Date�� Final Inspection by G� Additional Comments Z ❑ Stk 466-6781 0 Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385/pp Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, St)c., CA 9520 c� �� yelo X39 FEE INFO AMOUNT DUE AMOUNT REMITTED CK H RECEIVED BY DATE PERMIT-NO. +.EH53-24 1REV-t/m5) EH 14-28 r '