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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON 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 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address ZM, t+e_rmar of Brandt and 88 City 'ggk*f*rA Lot Size PM Owner's Name CrIILi6 Mska7 Addres25081. Grakam Rd Phone 04-2900 4 Contractor's Name _Thayer Well Dr11_U0i1*se No. _391542 Phone M-3119 1 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ W A PUMP MSTALLATION-It SYSTEM REPAIR-171- THEIR ❑ _ - 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 v,. ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation t ---Approx. Depth ❑ Eastern Surface Seal Installed by � Repair Work Done ;❑ Type of Pump H.P. !Lri State Work Done: Well Destruction ❑ Well Diameter Sealing Material (top 50') _ O Depth Filler Material (Below 501 O(1 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is .� available within 200 feet.) Installation will serve: , Residence_ Commercial_ Other 3y Number of living units:' Number of bedrooms Character of soil to a depth of 3 feet: Water table depth 2 SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑1 4 Method of Disposal Distance to nearest: Well t Foundation *. frit f Property Line LEACHING LINE ❑ No. & Length of lines Total length/size ' FILTER BED ❑ Distance to nearest:. Well Foundation Property Line ' SEEPAGE PITS ❑ Depth Size Number a SUMPS ❑ Distance to nearest: Well Foundation Property Line 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. s ` 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•permit4s-issued,nl•shall-employ-persons subject to workman's compensa- tion laws of California." ; R The applicant muol call for all required 1nsyectionq&XJWP1bte drawing on reverse side. Signed X f`Title: _ 111 _� W011 Dr1111nr I Date: Feb._5 1985 rJr.. 1A - FOR DEPARTMENT USE ONLY Application Accepted by Date n Area Pit or Grout Inspection by - =- Date--- -- —Final-inspection-by-��- 'J dX,r� /Ifle-4. .'•.Dates Additional Comments: ❑ Stk 466-6781 ❑ Codi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.Q. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE (A�M,OUN�T REMITTEDCASH RECEIVED BY -:%/ YDATE PERMIT''NO. + EH 14-28 iflEV.101831 S. Ob ''lam/ sas S N�