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APPLICATION FOR PERMIT toSAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA U t/C�' fAl Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED I l a-r (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 .3 miles W. Of `1W'26--501 S. Of City Lot Size PM RJm Calaveras River ) ;n 7 Owner's NameJOe Gotelli & SOnS Address 9392 N. Hildreth Lane Stomion ��} � ContractorPurViance Drille,rsoXAV P. O. BOX 64 License No. 377923 Phone_887-3554 I TYPE OF WELL/PUMP: NEW WELL X WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP, LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS JI INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation 16 Dia. of Well Casing 160D 7 El Domestic/Private 171 Gravel Pack ❑ Tracy Type of Casing Steel Specifications f+ F1 Public ❑ Other Cl Delta Depth of Grout Seal _ d Type of Grout cement _1 X Irrigation 4L5—QApprox. Depth I i Eastern Surface Seal installed by ..� i Repair Work Done F❑ Type of Pump H.P. State Work Done_ W Well Destruction ❑ Well Diameter Sealing Material (top 501 1 Depth Filler Material (Below 50') j TYPE OF SEPTIC WORK: NEW INSTALLATION l I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted it 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 I � 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 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 must Io all Mired inspections. Complete drawing on reverse side. - "' Signed President Title: Date: 3/18/88 FOR DEPARTMENT USE ONLY Application Accepted by (� Date 3-2Z . Area `' 1 Pit or Grout Inspection by Date a Final Inction by Rate Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 LI Manteca 823-7104 ❑ Tracy 835-6385 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 CK SW RECEIVED BY DATE PERMIT'NO. INFO + EH13.24 iREV.I i NS) �/ / / -Z ..-{ EH 1428 C/