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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT E E)" 1601 E. HAZELTON AVE., STOCKTON, CA R E C E I V Telephone (209) 466-6781 F E B PERMIT EXPIRES 1 YEAR FROM DATE ISSUE (Complete in Triplicate) VtRO IMIENTAL HEALTH P£PNI'T/FERV�ES Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein descr&d. is application is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for welUpump and the Rules and Regulations of the San Joaquin Local Health District. Job Address City Lot Size PM Owner's Name Leo Warmerdam Address 1601 W. Peltier Rd. Phone 17754 N. Hwy. 88 ContraclorGoehring PUmp Address Lockeford CA License No.309031 Phone 727-5548 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR X OTHER ❑ 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,SPEGIFfGAT#ONS-•- -- --• - - • - ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications f'1 Public Cl Other F1 Delta Depth of Grout Seal Type of Grout _ I I Irrigation Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done )(X Type of Pump Turbine H.P. 75 , State Work Done_ repair the turbine i Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50') _ TYPE OF SEPTIC WORK: NEW INSTALLATION i 1 REPAIRIADDITION l I DESTRUCTION ( Iko septic system permitted if public sewer is avWailable within 200 feet.) 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 1� FILTER BED El Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number L SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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 nature 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 a r as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the following: "I at 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 f f i i pact'ons. Complete drawing on reverse side. Signed X Title: Date: _- 2/7/91 OR DEPARTMENT USE ONLY /1 Application Accepted by Date "� �Z Area Pit or Grout Inspection by Date Final Inspection b _�L Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 0 Tracy 835-6385 Applicant - #return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOU T REMITTED CK 49 CASH RECEIVED BY DATE }PERMIT No. + EH13-24IREV.�/y51 � EH 11-28 �./