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' APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 9 YEAR FROM DATE ISSUED d <br /> (Complete in Triplicate) <br /> or <br /> ali the work herein describe . <br /> is <br /> cation is <br /> ' madlec inti <br /> ompliance with SanoJoaqu nthe SanCouJoanty Ordinauin lnc{e No.549 for sewage or ealth District for a permit <br /> No. 1862 for cwe I/dpump and the Rules and Regulations of tthe San l Joaquin <br /> Local Health District. <br /> Job Address 7076)9,' HWY. 12,Lodi,Ca. City r.nr19 Lot Size 2$aCres PM <br /> Leonard Thompson Address 2'1030 N, Davis Rd.Lodi Ca Pt,one 369®-20 <br /> 60 <br /> Owner's Name -- Ga1t,Ca..95632 <br /> Contractor <br /> Woods Well Dri.lg'*Address <br /> r 11944 Simmerhorn RdEicense No. 2$2$6b Phone_ 745-2407 <br /> TYPE OF WELL/PUMP: NEW WELA1 <br /> WELL REPLACEMENT El OTHER <br /> ❑ ° <br /> PUMP INSTALLAT10 SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO-NEAREST: SEPTIC TANK .� _. SEWER LINES'.— DISPOSAL FLD. _ <br /> FOUNDATION �Sr— AGRICULruRE WELL OTHER WELL.- PITS!SUMPS — <br /> WTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Bat <br /> ❑ Industrial jJ Open Bottom ❑ Manteca Dia. of Well Excavation A Dia. of Well Casing <br /> ' Steel Specifications 12 ga. b <br /> Z Domestic/Private ❑ Gravel Pack ❑Tracy Type of Casing � $ p � � <br /> F1 Other Cl Delta Depth of Grout Seal ®� Type of Grout Sand, <br /> � c em <br /> F1 Public ®Odsr <br /> I 1 Irrigation ­Approx. Depth 1 I Eastern Surface Seal Installed by <br /> Repair Work Done O Type of Pump Submerskhp State Work Done_ <br /> Well Destruction ❑ Well Diameter Sealing Material(top 501 <br /> Depth Filler Material (Below 501 <br /> ' TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence, Commercial_" Other ; <br /> w Number of living units: Number of bedrooms <br /> ' r^!Wtpg table depth — <br /> Character of soil to a depth of 3 fleet: <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT.❑ _ Method of Disposal ) <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance 110nearest: Well Foundation Property Line <br /> SEEPAGE PITS _ I I Depth Size Number <br /> " `SUIVi6'S T° L-I 'Distance to nearest: T Well'" Foundation '" Property'Lne� <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that I have prepared this applicatdor,and that the work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> vules and regulations of the San Joaquin Local Health District. <br /> 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 <br /> employ any person in such manner as to become subject to workman's compensation laws of California.' Contractors hiring or sub-contracting signature <br /> certifies the following: -5 certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of California." e <br /> The applicant must ca11 f all re uir®d'inspections. Complete drawing on reverse side. <br /> Y <br /> Signed I( Title: .Contractor Date0. l0/8S <br /> z I <br /> JOB I7EPAF1Tf1AEfYT 0.ASlm ONLY <br /> s --&---- `'-_ - <br /> Application Accepted by �^— Oat® Ar®a /y <br /> � .6 uq DateFu� <br /> Pit or Grout inspection by Date Final Inspection by <br /> Aqq <br /> Additional Comments: 8 <br /> ❑ Stk 466 Fi769 <br /> boy <br /> ❑ Mant a 823-7104 ❑ Tracy 835-6385 �• t ; tg_.,.- „tw, <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazolton Ave., P,O, lox 2006, Stk., CA 95201 <br /> FEE CIC RECEIVED By DAYS PERPAtT P10. <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH �]�f{y �% yyt <br /> c Erg 13-24IREV.1/051 �Q �� �� <br /> ' EN 14-26 <br />