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1 APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT �:� 1601 E. HAZETON AVE., STOCKTON, CA ri2' Telephone (209) 466-6781 $ PERMIT EXPIRES TYEAR FROM DATE ISSUED C� (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 describPtcjtslThls ication is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and the Rules and �sf; aan Joaquin Local Health District. tK{��1, Job Address 14900 W. Hwy. 12 City Terminous Lot Size PM r 14900 W Hwy. 12 Owner's Name MR. Steve Woodward Address Terminous, CA 95240 Phone (209) 369-1041 P.O. Sox 535 Contractor ASE Drilling Address San Ramon, CA 94583 License No.C57-487000 Phone (415) 820-11350 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER N 6 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 1 r ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing -❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications (l Public F] 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 ❑ Type of Pump H.P- State Work Done_ Well Destruction ❑ Well Diameter Sealing Material {top 501 Depth Filler Material {Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I.T REPAIR/ADDITION l 1 DESTRUCTION l 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 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 l I Depth Size Number SUMPS Cl 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. 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 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 st call for all re wired inspections. Complete drawing on reverse side. J?!� �"I1II�617 f�7e+ 1 (Yl/�Lllf� Date: Signed X /�� Title: ri AV` 17U F D A T USE ONLY Application Accepted by Date Area Pit or Grout Inspect' (� y Date Final Inspection by _ Date� �r 1 s Additional Comments ❑ Stk 466-6781 Q/1!od! 369-3 Manteca -7104 ❑ T acv 835-6385 c� 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 K INFO RECEIVED BY DATE PERMIT NO. /`y— �t�/&F7 * EH 3-24EH 14-26(REV.1 i H 51 � (/y i