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APPLICATION FOR PERMIT S'. SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED I (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. i x r Job Address 14900 W. Hwy 12 City Termin Lot Size PM t Owner's Name Steve Woodard Address 14900 W . Hwy 12, T erminous.CA Phone .209 369 1041 Contractor Aqua Science Engine_erAddress PO Box 535, San Ramon License No, 487000(C570hone_415 -B20 919 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ 6 PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER NK soil borings 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 { II ❑ Industrial LJ Open Bottom ❑ Manteca Dia- of Well Excavation Dia. of Well Casing I ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications neat cement y I' ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout bentonite ,I 1 1 Irrigation _..Approx, Depth I I Eastern Surface Seal Installed by ti 4 Repair Work Done ❑ Type of Pump H.P. State Work Done .t Well Destruction ❑ Well Diameter Sealing Material {top 501 neat cement/bentonite „slurry�4% bent ) Depth 15 feet Filler Material (Below 501 I TYPE OF SEPTIC WORK: NEW INSTALLATION {1 REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted it public sewer is available within 200 feet.) Installatidn will se`ve:-"Resid6)hce- ' -'Commercial-Other' " "°' " ~°L +- '!*"" 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 FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I 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 I, 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 µ 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 applican call for all r ed inspections. Complete drawing on reverse side. i 11 Signed x Title: Environmental, Specialist Date: 8-17-88 F EPARTMENT USE ONLY - 'i Application Accepted by Date IZ3��` Area Q� Pit or Grout Inspection by .Date Final Inspection by Date v 1 Additional Comments: ❑ Stk `466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Appli ant - Return all ce to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 I a iroIg*-s 4 L& PP- — FEE ;I INFO AMOUNT DUE AMOUNT REMITTED DASH RECEIVED BY DATE PERMIT NO. + EH 13-24 IttEV.t i x 51 t� :3�' !�/7� 9__Z5 Z5�� 2 EH 14-29 / V rs� i