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:. APPLIbATION FOR PERMIT SAN JOAQUIN-LOCAL HEALTH DISTRICT- 1601 ISTRICT1601 E. HAZEION AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUEDf (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 or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address ' s SOW $' Rdr LOdCity L*di Lot Size 40 ad � PM 4 Owner's Name Ralph AUdersvn Address 26190 T Sowel S RdissaM Phone- 36A.712A Contractor Woods Well r�ress .11944 Siittmil!lrhorn _RdLicense No. 2$2BG6Phone TYPE OF WELL/PUMP: NEW WELOPE WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATIONXX SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK 150A SEWER LINES 1.50.1 DISPOSAL FLD. 150 tPROP. LINE loci FOUNDATION : AGRICULTURE WELL 600' OTHER WELL. _- PITS/SUMPS ] INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS j�/ 16N _❑ Industrial )tXOpen Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing X1 DomesticlPrivate `' Gravel Pack LJ Tracy Type of CasingSte��+ Specifications 10 ❑ Public ❑ Other ❑ Delta Depth of Grout Seal SW Type of Grout Sand D ❑ Irrigation _-4ppr6x. Depth ❑ Eastern Surface Seal Installed by es Repair Work Done Ll Type of Pump sr, b H.P. S State Work Done Well Destruction ❑ Well Diameter Sealing Material {top 501 4- Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sower-is V% available within 200 feet.) O 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 r SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal " Distance to nearest: Well Foundation Property Line d LEACHING LINE ❑ No. & Length of lines Total length/size � l•'s FILTER BED ❑ Distance to nearest:. Well Foundation Property-Line SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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. l 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 l 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//regOr ed inspecti s. Complete drawing on reverse side. Signed Title: Contractor Date: $/7/89 FOR DEPARTMENT USE ONLY '! Application Accepted by Date ~ t' M Area Pit or Grout Inspection by F wte Final Inspection by K^--tate Additional Comments: ,k.. I ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy , Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk„ CA 95201FEE 1 INFO AMOUNT DUE AMOUNT REMITTED CA H RECEIVED BY DATE PERMIT'NO. I + EH 13-24(REV.1/85) EH �u- J.v (� � j 1428 ! a O