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hREDEIIVED APPLICATION FOR PERMIT } SAN JOAQUIN LOCAL HEALTH DISTRICT JAN 2 11983 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 kNVIRONMENTAL HEALTH PERMIT EXPIRES 1 YEAR FROM DATE ISSUED PEWIT I SERV ICES (Complete in Triplicate) is hereb made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. This application is- Application Y unty Ordinance Na. 549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin made in compliance with San Joaquin Co Local Health District. Job Address •3 mile Soth of Edwards Rd. : 502 W Campbell LkW;te C r PM Oakdale Irrigation D,7jt p• 0- SOX 188 y Oakdale Phone 847-0341 Owners Name �., 377923 Phone_887-3554 �lviance4ri11ers Drilling Address P• O• Box-`647LindenU;cense No._ �_�--- Contrac o DESTRUCTION NEW WELL ❑ WELL REPLACEMENT ❑ E) >atrl repair TYPE OF WELL/PUMP: . SYSTEM REPAIR D OTHER I� pump� PUMP INSTALLATION ❑ DISPOSAL FLD. PROP. LINE i DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES _ FOUNDATION` AGRICULTURE-WELL = OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS pia. of Well Casing ❑ Industrial LJOpen Bottom ❑ Manteca Dia. of Well Excavation T e of Casin Specifications E ❑ Domestic/Private ❑ Gravel Pack El Tracy YP g i ❑ Delta Depth of Grout Seal Type of Grout fl Public ❑ Other _ I I Irrigation _.Appro) Depth I I Eastern Surface Seal Installed by repair tube line, Type of Pump turbine H.P. State Work Done Repair Work gone bearirigS� rebuild Well Destruction 0 Well Diameter Sealing Material [top 501 bQW1S o Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: .-NEW INSTALLATION.[ RF -ADDITION-1=1 DESTRUCT-ION I I_available-septiwi hin 200 feet.) if public-sewer is Installation will serve: Residence_ Commercial Other Number of living units: Number of bedrooms Water table depth Character of soil to a depth of 3 feet: Ca acit No. Compartments SEPTIC TANK F1Type/Mfg Capacity— Method of Disposal PKG. TREATMENT PLT. ❑ Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total lengthtsize FILTER BED ❑ Distance to nearest: Well ;Foundation Property Line SEEPAGE PITS I 1 Depth Size Number ? SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDSv ❑l F I hereby certify that I have prepared chis 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. t 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 parson 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 I tion laws of California." The applicant must call fo II wired inspections. Complete drawing on'reverse side. 1�1$�88 � Signed X Title: President Date: FOR_DEPARTMENT USE ONLY r Date 2-- i —. Area I Application Accepted by � Pit or Grout Inspection by Date Final Inspection by Date /a l Additional Comments: I ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 I Applicant Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 20og, Stk., CA 95201 i FE CK RECEIVED BY DATE PERMIT'NO. O AMOUNT DUE AMOUNT REMITTED CASH INF ♦ EH 13-241REV.i/H51 EH 14-26