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tom* f / APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 1— PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to the San J aquin 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 or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. 13130 Eo Peltier Rd. , Acampo, 95220 Job Address .3 mile E Pearl Rd./.45M/S of Pelti, r Lot Size PM Owner Name Vino Farms Address 508 W. Loekeford St. sLodiPhone 334-6975 Contractor Purviance�Dril3ers�d�rc. P. 0. BOX 64,Lin , no. 377923 Phone 887-3554 TYPE OF WELL/PUMP: NEW WELL R WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca" Dia. of Well Excavation Dia. of Well Casing) 160D W f. ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type"of Casing steel Specifications ~ FI Public n Other ❑ Delta Depth of Grout Seal —0— Type of Grout JK Irrigation _..Approx; Depth 1 1.Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction . ❑ Well Diameter Sealing Material {top 501 'it Depth i Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR/ADDITION t I ` DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedr'ooII s Character of soil to a depth of 3 feet: 1 __Water table depth p ` SEPTIC TANK ❑ Type/Mfg t as Capacity No. Compartments Ill Method of Dis oral PKG. TREATMENT PLT- ❑ �, � � P Distance to nearest:` Well 4"'" "'"" Foundation Property Line I I Al+- LEACHING LINE ❑ No. & Length of lines Total lengthlsize x" FILTER BED '❑ Distance to nearest: Well Foundabon Property Line I SEEPAGE PITS i I Depth Size Number h SUMPS Li Distance?to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I I hereby certify that I have prepared this application and that the work will be done in accordance with Sart 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 certifytha nth performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- 4 tion laws of California." =f The appiic nt st call for r inspections. Complete drawing on reverse side. Signed _F - e. President Date: 3/15/89 FOR DEPARTMENT USE ONLY c� Application Accepted by Date 2- 7 D Area } Pit or Grout Inspection by Date Final Inspection by ^ /° Date r✓ 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 CK RECEIVED By DATE PERMIT NO. INFO CASH +.EH 13-24IREv,1i451 EH 14-28 _ _ _.,.... -