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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT QF 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466.6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Y r-r (Complete in Triplicate)r f 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 incompliancewith 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 1 , City Lodi Lot Size 15 Ac PM I Owner's Name Galen Johnson Address 11205 N Hwy_99 Phone 36 $16 Contractor's Name Tho er We 11 Drill: License No. 391542 TYPE OF WELL/PUMP: - Phone 34- 130 NEW WEI _o WELL REPLACEMENT f] DESTRUCTION ❑ `PUiMMNSTACCATION'❑" ------ SYSTEM-AEP41R p-- ------- -. _ DISTANCE TO NEAREST: SEPTIC OTHER-❑ -� " �. L SEWER LINES DISPOSAL FLD. ^ I _- ! FOUNDATION _- ' _ "".'_��:'_ �--------- — PROP: LINE I —65AGRICULTURE WELL 75+ OTHER WELL r INTENDED USE -=�.-.PITS/SUMPS s - a, hTYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS - ❑ Industrial ?a'Open Bottom' ❑-Mariteba Dia. of Well Excavation Dia. of Well Casing 8" Ek Domestic/Private ; ' ❑ Gravel Pack ❑ Tracy_' T D Public - +❑ ,Other Type of Casing steel Specifications 10 g4- f El Delta Depth of Grout Seal 50 ❑ irrigation TM, � � Type of Grout Sk 1 Approx.Depth—❑-Eastern _,�,_�,SurfaceSeal fnstalied_by_ Stet/ Thayer Repair Work Done ❑ Type of Pump :H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material atop}50') Depth Filler Material (Belonr'5o,),�-'- TYPE OF SEPTIC WOAK:.�`NEW INSTALLATION❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is +� ( Installation will.serve: 1 Residence. l:� r available within 200 feet.) { Commercial_ Other, Number,of,.iving"units"--'•" ,Number of bedrooms Character of soil to a depth of 3 feet:{"' SEPTIC TANK ' . 1 Water table depth { .� 1❑ Type/Mfg r a- PKG. TREATI ENT"PtT:L❑ + = I'` .Capacity - No. Compartments �J Method of Disposal i i Distance-to_nearest `� Well` - FoundationProperty Line �Jr LEACHING LINE ❑ No. & Length Length of of lineses Total"length/size t FILTER BED ❑ Distance to nearest: >Well Foundatianr A 3 M /Property Line -SEEPAGE-PITS- �- 1 E--Depth- vzef �..._. SUMPS Number-s - ❑ Distance to nearest.4` --Well- i 'Foundation DISPOSAL PONDS 110 Property Line 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 com certifies the following: pensation laws of California."Contractors hiring or sub-contracting signature g: ''i certify that in the performance tion laws of C lifornia." of the work for which this permit is issued, I shall employ.persons subject to workman's compensa- G � The applica ust c ired iplete drawing on reverse side. t Signed �:ICorr - Title: Date: Sept 15, IQ86 !� FOR DE RTMENT USE ONLY Application Accepted by �� Date*. Area ®� Pit Grout In pection by Date �. .. Final Area bDate Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-36211 ❑ 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 85201 ` F -- --- -FEE- INFO FEE t' INFO AMOUNT`DtIE"-- A14OUNT,9EKM1lTT5D _CK-4 CASH �`�REC�IGED'B17"T �, DATE • PERhiIIT"IVO:"'""' + EH 12-24[REV.101831 �^-� EH 14-28 J Q -.' r . l