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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 4-3 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED �`'�-EP (Complete in Triplicate) iL rAL.i ` e., r> roi�i c, „� Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work-ker�ih{dgscgE�tCt,�&lication 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. CROSS BRIDGE ONTO BACON ISLAND, TURN RIaff, GD 1.2 MILES. Job Address TURN LEFT AT DEL RIO FARMS SIGN m 1.8 MTI FS T city RLnN TSI ANDot Size PM END. owner's Name DEL RIO FARMS Address P -0- R O X 343 S T O r K T O N Phone -464_ 797 Contractor H F N N T N C S R R Q S Address 3 5 2& p-E L.A.N D A L E A 1.1 F=- License No. 2 0�-1-� Phone TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK Ur&r 1001 SEWER LINES —100 t 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 Excavation1� 1 2 Dia. of Well Casing 1f IX Domestic/Private X Gravel Pack ❑ Tracy Type of Casing PVC wo� Specifications F1 Public ❑ Other ❑ Delta Depth of Grout Seal 1A--A Type of Grout R E N T n M JE I I Irrigation Approx. Depth 11 Eastern Surface Seal Installed by H F N N T N G S B R 0 Repair Work Done ❑ Type of Pump IS A N D.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION 1 I DESTRUCTION f I (No septic system permitted if public sewer is ,IC_ Installation will serve: Residence_ Commercial_ Other available within 200 feet.) Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth Z SEPTIC TANK ❑ Type/Mfg Capacity_P Y 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 SUMPS Cl Distance to nearest: Well Foundation DISPOSAL PONDS ❑ Property Line 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 must call for all required inspections. Complete dr wing on reverse side. Signed X 1r VVTitl _ l D Date: l 00 R DEPARTMENT USE ONLY Application Accepted by Date Area Pit or Grout Inspection by ate Final Inspection by f� ( Date � 70 Additional Comments: (a. u Q ( ( r— (( '1 ( S ❑ Stk 466-6781 ❑ Lodi 3,,-3621 ❑ Manteca 1123-71104 ❑ 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 INFO RECEIVED BY DATE PERMIT'NO. + EH 13-24(REV.i i H 5 EH 14-26 9 Com--