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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT t' 1601 E. HAZE T 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. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. f Job AddressCity .-�Esc l o1: - Lot Size PM Owner's Name Dairy, Address E Holmstead Dair Inc 10048 Sexton Rd. scalon Phone ` ContractoPuryiance Dri1lerSAdd;,9C s P.o.Box 64, LindeQicease No. 377923 Phone 887-3554 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION X PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES ' DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom 0 Manteca Dia.'of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type-of Casing Steel Specifications 1-1 Public lei (yher 171 Delta Depth of Grout Seal Type of Grout v I I Irrigation 3 _-Approx. Depth I 1 Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P, State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') $xyR 6 Sack cement Depth Filler Material (Below 50') Sand & graVel �2D fit TYPE OF SEPTIC WORK: NEW INSTALLATION ;1 REPAIR/ADDITION I I DESTRUCTION i 1 (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 tL - Distance to nearest: Well Foundation Property Line '1 A 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 ❑ Distance to nearest: Well Foundation ' Property Line DISPOSAL PONDS ❑ R- 1 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 Di§trict. I 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 lifornia." The ap licant p9st call f II re ired inspections. Complete drawing on reverse side Signed Title: Date: a=��-NT_IJSE ONLY n Application Accepted by Date `l 1 - Area Pit or Grout Inspection by Date Final Inspection by Date Yt+�c�.e� .mss1 cciLEd z et! w, �i4 - err, zeros o tz war .e+rr.v.e4! •ir �� w Additional Comments: ❑ Stk 466-6781 El Lodi 369-3621 ❑ a teca -7104 ❑ Tracy 835-6385 wc!/ 7S 60'. 7—At. ,.,.! Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.D. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. INFO CASH/ +.EH1 -241REV.1i85) C? pyo EH 144-28 I