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lY� APPLICATION FOR PERMIT 5 OHM 941111 loll SAN JOAQUIN LOCAL HEALTH DISTRICTftuE Ew I V 1601 E. HAZELTON AVE., STOCKTON, CA Telephone 12091 466-6781 NOV 1 7 1989 � PERMIT EXPIRES 1 YEAR FROM DATE ISSUE VIRONMENTAL HEATH (Complete in Triplicate) PERMIT/SERVICES Application is hereby made to the San Joaquin Local Health District for a permit to construct andlor 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. Jab Address 1967 De Lima Rd. City Lot Size 3acre PM Owner's Name Bill SChendel Address 1700 11C Henry ,AVE Modesto, Ca. Phone RRk 522-8981 q5� 95357 Contractor Stani.slaus P Address P.O. BOX 57-6125 AMNSWense No. 290355 Phone 551-7867 TYPE OF WELL/PUMP: NEW WELLEl WELL REPLACEMENT El DESTRUCTION ❑ PUMP INSTALLATIOf, SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANKQ)Mr; 100� SEWER LINES DISPOSAL FLDEver101DAOP. LINE Y FOt]NDATION— �B�U c.-- ' GRICULTURE WELL INP Y`PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ElIndustrial ❑ Open Bottom ElManteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications FI Public ❑ Other Ll Delta Depth of Grout Seal Type of Grout--- I rout I I Irrigation —.Approx. Depth l I Eastern Surface Seal Installed by - Repair Work Done ❑ Type of Pump au—k—mer9-iblEH.P.lhhp State Work Done Tncf-al l new sub pump Well Destruction ❑ Well Diameter Sealing Material (top 50'1 in nrK-- Depth Fillet Material (Below 50') — TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is 5` available within 200 feet.) 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 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 1 Depth Size Number _ ' 9* SUMPS, - ---- �Lrl—Distance to nearest: -Well- �_Foundatiom 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 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 appli nt mu t calk for II re wire ms ctions. Compl to dr win on reverse side. —111! — ana �atxs t la N & crost. Corp. Signed X Title: Date: DEPARTMENT USE ONLY i j / i n Accepted b F�� Date Area 4r 0 Applicata p y I Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: ❑ Stk �f3i3H )E Lodi 369-3621 ❑ Manteca 823-7104 CI Tracy 835-6385 Applicant - eturn a copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 r FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. INFO �y + EH 13-24 MEV.1/H sl - EH 14-2e �'�\