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APPLICATION FOR PERMIT ^� a SAN JOAQUIN LOCAL HEALTH DISTRICT " 1601 E. HAZEL T ON AVE., STOCKTON, CAS Telephone (209) 466-6781 t ' PERMIT EXPIRES 1-YEAR FROM DATE ISSUED I (Complete in Triplicate) Application is hereby made to the San'Joaquin Local Heaith District for a permit to construct and/or instail the work herein described. 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. a X17,4_77-E:.;-I?y. °:1)24 ;?i onu r� Job Address_ - - - - -- f- _ "_ _ City- - - _ L� Lot size acres_. _ PM Bob Tmfeld � � 17477 E. Hy. 120_ , Ripon, Ca. 83"- Owner's Name Address'_ Phone Cantrcttar 0—GARNER C N T� RUCTIQN Address 79no Wren R,+- nakrial p License No.A-R ddl,96SPhoneR47-1490 TYPE OF WELL/PUMP: .NEW WELL ❑ WELL RE?LACEMENT ❑ DESTRUCTION 0 PUMP INSTALLATION ❑ SYS T iIM REPAIR ❑ OTHER ❑ DIS"ANCE TO NEAREST: SE?TIC TANK SEWER LINES DISPOSAL FLO. PROP. UNE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS IN`ENDED USE. TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS G Incustriaf ❑ Open Bottom, G Manteca Dia. of Well Excavation Dia. of Well Casing -r El Domestic/Private G Gravel Pack ❑Tracy Type of Casing Specifications 1 FI Puolic C Other fn Delta Depth of Grout Seal Type of Grout I i Irngation _Approx. Depth I 1 Eastern Surface Seal Installed by _ Repair Work Done ❑ Type of Pump H.P. ''Stale Work Done_ Well Destruction ❑ Well Diameter Sealing Material {top 501 Depth Filler Material iBelow 50'1 TYPE OF SEPTIC WORK; NEW INSTALLATION X REPAIR/ADDITION X DESTRUCTION I I INo septic system permitted if public sewer is I available within 200 feet.) Installation will serve: Residence X Commercial_ Other Number of living units: 1 Number of bedrooms 3 Character of soil to a depth of 3 feet: Har'd'pan Water table depthl0or 'f• - r SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT,C3 Method of Disposal Distance to nearest: Well Foundation Property Line _t - LEACHING LINE 2F No. & Length of lines _ 1 X -40 lin ft: Total length/size 1 X 40 t 80 _Sq. -ft. FILTER BED ❑ Distance tonearest: Well 102 1_' Feu•ndation 120Property Line 62 - SEEPAGE PITS IAC ..Depth 16' Size 3'_--w/14_'- L Ntimber SUMPS ❑ Distance to nearest: Well 102 Foundation.140 Property Line 25'. DISPOSAL PONDS El 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 I rules and regulations of the San Joaquin Local Health Drstrict. 1 Home owner or licensed agents 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-, "1 certify that in the performance of the work for which this permit is issued, l shall employ persons subject to workman's compensa- tion laws of California." r The applicant must cal for all required inspections. Complete drawing on reverse side. E Signed X - Title: w n r n r C o n s t r U C t i o n Date. 8-7-92 i DEPA MENT ONLY _ Application Accepted by ZDate£- tea Pit or Grout Inspection by Date Final Inspection b Date 7 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 p INFOEAMOUNT DUE '' AMOUNT REMITTED GASH RECEIVED BY DATE PERMIT'No. [ Y r r EH la- a(REV. i n 51 /J Q / a. ,( ��•y� y,� EH laza /� /