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AT . Y APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1 vhf^ 1601 E. HAZELTON AVE., STOCKTON, CA 0 0 Telephone (209) 466-6781 I � � PERMIT EXPIRES TYEAR FROM DATE ISSUED t (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District fora 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 I Local Health District. Job Address 456Mile w. ofl.-Jack Tone x 75 N ,of cit Y Lot Size PM Calavaras River} Owner's Name Roy DeM-iPmchenZi Address 122671,E . 8 Mile Rd. Phone 931-3486 - Contra ctJ?UrVi idY1Ce Drillers., AlMas P. 0. Box +64 Linde-1cense No. 377923 Phane 887-3554 ; _ TYPE OF WELL/PUMP:. + . NEW WELLA WELL REPLACEMENT ❑ DESTRUCTION Q N � _ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ I �1 DISTANCE TO NEAREST: SEPTIC TANK,. SEWER LINES DISPOSAL FLD. PROP. LINE j FOUNDATION AGRICULTURE WELL. OTHER WELL PITS/SUMPS I I a INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing 1.410D J Domestic/Private ❑ Gravel Pack ❑ Tracy Type of'Casin tee 9 Sl Specifications M Public Cl Other C1 Delta Depth of Grout Seal 50 ' t tr 1,q Type of Graut CE'TC1P�k11 4 4, I Irrigation 5� pprox. Depth l I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump turbine H_p. 30 f State Work DonereZnstallln eX$1StJ Well Destruction ❑ Well Diameter. vl Sealing Material (top 50') --------Pump in new well. + ,� (� Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION [] REPAIR/ADDITION { I' DESTRUCTION ( I (No septic system permitted if public sewer is available within 200 feet.) Y 'Installation will serve:,Residence� Commercial_ Other z Number of living units: Number of bedrooms f Character of soil to a depth of 3 feet- SEPTIC eet: Water table depth SEPTIC.TANK LJType/Mfg Ca'acit��r � P y No. Compartments PKG. TREATMENT PLT. ❑' a. ¢ Method of Disposal Distance to nearest: Well Foundation r wtr Property Line LEACHING EINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Fouridation Property Line 7 SEEPAGE PITS I I Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line -DISPOSAL PONDS ❑ 1 I hereby certify that f 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, l 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 pficant m t call r all r 'ad ins r q peciioas. Complete drawing on reverse side. .� w Signed .t?i Title: Corpe Secreti! Date: _.- 3/22/88 FOR DEPARTMENT USE ONLY Application Accepted by Date Area Pit or Grout Inspection byDate�Z3 0' nal Inspection by Date Additional Comments: LI. Vit/ lv. ✓1 4- LJ ❑ Stk 466-6781 ❑ Lodi 369-9621 ❑ Manteca 823-7104 El Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED k INFO /// i CK H RECEIVED BY DATE PERMIT'NO. + EH 13-24 IREV.1/e .28 EH 1 V