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a APPLICATION FOR PERMIT PAYMENT j SAN JOAQUIN LOCAL HEALTH DISTRICT, RECEIVED-,", I i 1601 E. HAZEL T ON AVE., STOCKTON, CA 4 Telephone (2091 466-6781 AUG 3 198IR ' PERMIT EXPIRES 1-YEAR FROM DATE ISSUED TH (Complete in Triplicate? ENVIRONMENTAL HEAL FERMITISERVICES Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work erein de cribed. 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 Local Health District. ' Job Address 24330 Puhrm2an Rd, `City LockefordLot Size zaca PM Owner's Name.Dick Mayers ! Address 2224 Jaehson St.Lodi,CaX. Phone 3686495 GalttCa.95632 ' Contractor Woods -Well DrAll0 Address 11944Simmerhorn Rd. License No. 282866 Phone 745-2407 „TYPE OF WELL/PUMP: NEW WELL CR WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER C] -DISTANCE TO NEAREST: SEPTIC TANK"`_15Q SEWER LINES 1501 DISPOSAL FLD. PROP. LINE 751 $ f FOUNDATION � AGRICULTURE WELL OTHER WELL — PITSISUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial X7 Open Bottom ❑ Manteca Dia. of Well Excavation t Dia. of Well Casing 8t't CDomestic/Private . ❑ Gravel Pack ❑ Tracy Type of Casing Steel Specifications. F Public F Other ❑ Delta Depth of Grout Seal 50; Type of Grout Sa442Cerke t I I Irrigation -Approx. Depth l I Eastern Surface Seal Installed by Woods _ Repair Work Done 0 Type of Pump H.P. State Work Done \Z) Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I:) REPAIR/ADDITION I I DESTRUCTION I I lNo septic system permitted if public sewer is �►tij 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 I LEACHING LINE C No. & Length of lines Total length/size I FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size _ Number .SUMPS- - -- .Cl Distance to nearest: . --Well Y;Foundation Property.Line.-- DISPOSAL PONDS ❑ I I hereby certify that l 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 laws of California." The applicant must call for all required ins ons. Complete drawing on reverse side. Signed X Title: Contractor Dater 8/3/88 DEPAR ENT USE ONLY t' res `�'" ` Area Application Accepted by Date Pit or Grout Inspection by Date Final-inspection by, Date 7 C Additional Comments: ❑ 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 FEE AMOUNT DUE AMOUNT REMITTED I CK 11 RECEIVED BY_ DATE PERMIT•NO. INFO CASH EH 13-24(REV.t H s) EH 14-2 ' 01� 8 l�C} dCU/J