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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT ` 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED APR 8 198 —_ (Complete in Triplicate) ENVIROMENTAL H Application is hereby made to the San Joa in Local Health District for a permit to construct and/or install thegrj2her��i� s 86plicatiogn is made in compliance with San Joaquin County Or ina c No 549 for ewage of o. 186 for we11/pump and the Ru us and egu r ha San Joaquin Local Health District.® � �' 7�� l� 0 _f210-0-7 No Andress Av4ilable Job Address gge c1 an ora o City tot Size PM Owner's Name 3 OakS VineyardS Address 210 Phone 17754 N. H 8$ ice a No. 309031 Phone ContractorGOe�'1?"1ri�_ um�2�__Address — # TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ F PUMP INSTALLATION-M SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE r.._FQUNDATION- _AGRICULTURE WELL OTHER WELL PUTS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of,Casing Specifications "i FI Public Ll Other 1-1 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 Pumparblnt? H.P. _ 1 5 � _ State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50') 4 k TYPE OF SEPTIC WORK:—NEW-INSTAL-LATION l-1 REPAIWADDITION l I DESTRUCTION-I 1 iNo septic-system-permitted if public sewer is 'a Y S # available within 200 feet) Installation will't6rve: --- --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. ❑ j 7rr. ! t Method of Disposal Distance to nearest: .k.Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines €. 'i I 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 rules and regulations of the San Joaquin Local Health District. ys 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, hshall not employ any person insu manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies iha#ollowin artily 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 Calif r The applicant f 11 required inspections. Complete drawing on r er side. Signed X Title: Date: FOR DEPARTMENT USE ONLY , Application Accepted by Area Pate �J Pit or Grout Inspection by Date Final Inspection b � Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 635-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE A U UE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. INFO CASH + EH 13-241REV.i/rt 51 4g--Q EH 14-26 1 f