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i APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON 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. Job Address 27555 N. Cherokee Ln. City Lot Size 40 acres PM Owner's Name Martin McA.l,l.ister Address P.O. Box 192 Galt Ca. phone 745-1085 Contractor's Name Woods Well Drillil�nse No. 282866 Phone 745-2407 TYPE OF WELL/PUMP:-- NEW WELL 1X` WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION 4 SYST1001M RPAIR ❑ OTHER 1-1DISTANCE TO NEAREST: SEPTIC TANK 100 SEWER LINES DISPOSAL FLD. PROP. LINE 502 FOUNDATION - AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ? Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing 8tt Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications Public ❑ Other ❑ Delta Depth of Grout Sea! —0t T pe Grout .t C1 Irrigation 2�pprox. Depth El Eastern Surface Seal Installed by """�+s. well Drilling Repair Work Done ❑ Type of Pump Sul] H.P. 3 . State Work Done IIeW Well Destruction ❑ Well Diameter Sealing Material ftop 501 Depth Filler Material IBelow 501 J TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms Ul Character of soil tp.a depth of 3 feet: Water table depth SEPTIC TANK ❑ ;Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ _ ? Method of Disposal ' p66iarlce to nearest: Well Foundation Property Line LEACHING LINE ❑ Nb.`4 Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS:',; ❑ depth Size Number SUMPS ❑ ;Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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 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,I shall employ persons subject to workman's compensa- tion laws of California." The applicant must call for all required inspe ions. Complete drawing on reverse side. Signed )L( � �„ Title: Date: 5-1-86,_ FOR DEPARTMENT USE ONLY Application Accepted by' Date Area al PR orrout Inspection by Date -a �v 'Fnal Inspection b -e—) Date Additional Comments: _ ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ 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 95201 FEE INFO AMOU"T DUE AMOUNT REMITTED C H RECEIVED BY DATE PERMIT"NO. + EH 13-24(REV.10!83) EH 1426