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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 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 forsewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address 11890 N HWY 88 CitILpdi Lot Size PM Owner's Name Tim MartinezAddress3520 Higgins Av Stockton Pho 1-8502 Tho er Well Drilling,....Contractor's Name Dggense No.39152 — Phone 727"`3119 TYPE OF WELL/PUMP: NEW WELL WWELL REPRACEMENT'❑ - 770—ES�TRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR.LJ OTHER £J DISTANCE TO NEAREST: SEPTIC TANK _10" _ SEWER LINES DISPOSAL FLD. _ PROP. LINE FOUNDATION AGRICULTURE WELL'— OTHER WELL PITS/SUMPS =3go# INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial M Open Bottom ❑ Manteca Dia. of Wel! Excavation 1=11 Dia. of Well Casing 10 Domestic/Private © Gravel Pack © Tracy Type of Casingf,,,='T Specifications .125 ❑ Public ❑ Other ❑ Delta Depth of Grout Seal 5Q11 Type of Grout 9 Sk1 D Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump _subs_ H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is Z 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. ❑ A Method of Disposal .: Distance to nearest: TWell Foundation Property Line LEACHING LINE ❑ No. & 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 ❑ t 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 Icertify 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." Contractors 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 m t II for all r uir pections. e .rawind on reverse side. l s Signed - Title: � �A k Date. Feb? 1985 �6F DEPARTMENT-USE ONLY'�`, �i _ Applicati ccepted by Date ,�7—O��Area / �,�n I� Pit or rio Inspection by Date ==- -— Fina! Inspection by ��'Y�/ L G !! Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7704 ❑ Tracy 8355-6395 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. + EH13.24(REV.10/831 �/_!; / EH 1426 ��.. p� /5�,� �� 7