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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA 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 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 13191 N. Hwy 99 City St_kn Lot Size PM Owner's Name Iver Dickhoff Address 17644 Kenninabn Lodi – Phone 1 -334-2n66 Contractor Clark Well Address 2024 E. Charter License No. 371 560 Phone 4627676 .. TYPE OF WELL/PUMP: NEW WELLX(R WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATIONKC9 SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK +19 0 1 SEWER LINES DISPOSAL FLD. PROP. LINE 3,Q' FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _____ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation 4 Dia. of Well Casing 8 5 8 rr kkDomestic/Private Gravel Pack ❑ Tracy Type of Casing Steel __ Specifications#1 0 R M Public n 0 er 71 Delta Depth of Grout Seal � LAO Type of Grout 9 _qar-k I I Irrigation pprox. Depth i I Eastern Surface Seal Installed by Elark _ Repair Work Done U Type of Pump H.H.P. State Work Done _ install Well Destruction ❑ Well Diameter Sealing Material Itop 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I l 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 t ,� Number of living units: Number of bedrooms V 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 L1 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-0 rules and regulations of the San Joaquin Local Health District. Horne 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, 1 shall employ persons subject to workman's compensa- tion laws of Calif rnia." The applicant ca o all r ui a ins tion Complete drawing on reverse side. signed X Title. VP C 1 ;4 rk WP_1 1 Date. 2 5 A=r 9 0 FOR DEPARTMENT USE ONLY Application Accepted by i Date �y�y�}��I 0 Area I f Pit or Grout Inspection by n Date/ , �`'` Final Inspection by� Additional Comments: ! � � f � `��? >5 w J � o R6 ❑ Stk 466-6781 ❑ Lodi 369-3621 Manteca 823-7104 ❑ Tracy 83 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEECK INFO AMOUNT DUE AMOUNT REMITTED ASH RECEIVED BY DATE PERMIT'NO. + EH 13-24{REV.t i H 51 EH 14-2e