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r ' APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT I 1601 E. HAZETON 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. 1B62 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address 17320 8 Mile Rd. CityLinden Lot Size PM Owner's Name Joe GOtelll & Sons Address 9392 Hildreth Lane Phone 931-4302 I F ContractoF ryiancQ Drillerspdfn P.O.BOx 6 License No. -377973 Phone 887-35-94 ) TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION I& SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP, LINE 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 ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ("i Public f 1 Other ❑ Delta Depth of Grout Seal Type of Grout _ I I Irrigation —_-Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump turbine H.P. 80 HE State Work Done in, tallt-d puma in Well Destruction ❑ Well Diameter Sealing Material (top 501 new Well -- (— Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I] REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is 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 i 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 11 Depth Size _ Number SUMPS ❑ Distance to nearest: Well Foundation_ Property Line C i DISPOSAL PONDS ❑ �1 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 law 'fornia." The a plicant t call fo Iire4ired ' pections. Complete drawing on verse side. �rQ Signe Title: v Date: 4Y-19r k OR DEPAR ENT USE ONLYNO Application Accepted by Dates Area Pit or Grout Inspection by Date Final Inspection by Date��3U�� l Additional Comments: I ❑ 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 95241 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO- f INFO F{ CASH ( ` W 7 +.EHi3-24{REV,F/H5) �, ✓ V1 — '70- v EH 1426 ��v 1111 I _ r