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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT �0 1601 E. HAZEL T ON AVE., STOCKTON, CA PAYMENT j� Telephone (209) 466-6781 RECEIVED YI PERMIT EXPIRES TYEAR FROM DATE ISSUED LIAR 12 WO (Complete in Triplicate) J QIN. (;pj_jNTY P1�fi H pho, Application is hefeby made to the San Joaquin Local Health District for a permit to construct and/or install � PlicJoof aqq uin is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and ENVIR r R�i " Local Health District. Job Address 24801 S Austin Road city Ri non Lot Size 1R_ac PM p Owner's Name John Schaa man Address S amP Phone — 2049- Contractor N/A Address License No. Phone_ TYPE OF WELL/PUMP: NEW WELL Z] WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION U SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK 65 f t . SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS C7 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing C$Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications F1 Public ❑ 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 su 1�_ H.P. 1 h P --- State Work Done_ Well Destruction ❑ Well Diameter 6 J n Sealing Material (top 501 Depth 1 30 ft Filler Material (Below 50') -- TYPE OF SEPTIC WORK: NEW INSTALLATION l l REPAIR/ADDITION l I DESTRUCTION I I (No septic system ithin m emitted if public sewer is available eet 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 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 I I Depth Size _ Number A SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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 laws of California." The applicant ust call for I required inspections. Complete drawing on reverse side. Signed X Title: C/ - Date: Z Zg�U FOR EPARTMENT USE ONLY — �� ^a f Application Accepted by Date `y° rea / U Pit or Grout Inspection by Date Final Inspection by, Date- 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 RECEIVED BY DATE PERMIT NO. INFO i EH 13-24 IREV. i 5) 35 . 00C*__ ��(p o_90 —S97- EH 14-28