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APPLICATION FOR PERMIT y� +� SAN JOAQUIN LOCAL HEALTH DISTRICT ` ,.r 1 1601 E. HAZEL T ON AVE., STOCKTON, CA q5 , Telephone (209) 466-6781 PERMIT EXPIRES 1'YEAR FROM DATE ISSUED" { Complete tri Trlplicatef fpv Det iT ©YPLL HALH + N FtO�+ Application is hereby made to the San Joagwn Local Health District for a permit to"construct and/or install the work-IWiA §�edvLMsS application is made in compliance with San Joaquin County Ordinance No.549 for wa or No. 1862 for well/pump and the Rgles and Regulations of the San Joaquin wo Local Nl alth Distri-t. q l I} �..,Address .3 mile wort of Escalon/Bellotti 'R(dity, Linden Lot Size PM 250' north of Flood,Rd. 11 •' r - "Owner's Name" FoRt r F;j=s T Address 2857 Geer Rd. p -Turlock Phone ContractorRury-i anrp. Driller.%ddress P. 0. BOX 64-, LinCbQ)�lhse No. 377923 Phone 887-3554 . TYPE OF WELL/PUMP: NEW WELL.19 WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP"INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANKSEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA -CONSTRUCTION SPECIFICATIONS 10 11 ,odustrial EJ Open Bottom 11 Manteca Dia. of Well Excavation pia. of Well Casing omestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing 10ga Kai Well Specifications J rn ❑ Public ❑ Other ❑ Delta Depth of Grout Seal "! If Type of Grout rrigation 5"0pprox. Depth 1:1 Eastern Surface Seal Installed by a Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') +: Depth ' Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ c REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is davailable within"200 feet.): 41 Installation will serve: Residence— Commercial— Other Number of living units: Number of bedrooms p Character of soil to a depth of 3 feet: j Water table depth SEPTIC TANK ❑ Type/Mfgn Capacity No. Compartments .F_ PKG. TREATMENT PLT. ❑ Method of Disposal ' Distance to nearest:` ;Well Foundation Property Line x j LEACHING LINE ❑ Nor'& Length of lines .1 Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number t SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑.- P 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 h rules and regulations of the San Joaquin Local Health District. R 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 plicant.m t call f all qu d"inspections„Complete drawing on reverse side. Signed - '..T.;" "Tifle:"-'CQ=ate' Secretary Date: 6/1/87 - �V.FOR DEPARTMENT USE ONLY _� BVI\►J11Y-`r Application Accepted by Date Q` Area Pit or Grout Inspection by Date Final IKspection by Date Additional Comments: �� d ❑ 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 95201 if FIEE CK INFO AMOUNT AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT-NO. + EH 3-24(REV.F/as7 EH 1428 / "DY