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CNVIRO ENTAL HEALTH F ERMIT/SERVICES APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (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 .35 Mi south Comstock/50'East Of TiA+11y rd. Lot Size PM Owner's Name Morand0'._ ' _ - -^ Address 8956 TU11y Rdej Linden Phone Contr !CSDrllleMDrillingCOrp. Address P. O. Box 64,Linden License No. 3.77923 Phone 887-355 TYPE OF WELL/PUMP: DISTANCE TO NEAREST INTENDED USE ❑ Industrial ❑ Domestic/ Private (`l Public I I Irrigation Repair Work Done ❑ Well Destruction iffi TYPE OF SEPTIC WORK: NEW WELL ❑ WELL REPLACEMENT ER DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER 0 SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Other f 1 Delta Depth of Grout Seal G uellyp lost s ftoCee�F� a Approx. Depth I t Eastern Surface Seal installed by rtuTre e k D anC QSe , O Ouri i Type of Pump H. P. State or Done _._a4ding, so Ct Well Diameter 8�r Sealing Material (top 501 5 Sark sand rement __� be p( Depth 116 ! Filler Material (Below 50') f Itish. Wit] NEW INSTALLATION l 1 REPAIRlADDITION I 1 DESTRUCTION l I (No septic system permitted if f�pdeymAk. available within 200 feet.) Installation will serve: -Residence — -Commercial Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: SEPTIC TANK ❑ Type/Mfg PKG. TREATMENT PLT- ❑ Other Water table depth Capacity No. Compartments Distance to nearest; Well _ Foundation LEACHING LINE Cl No. & Length of lines Total FILTER BED ❑ Distance to nearest: Well Foundation SEEPAGE PITS ( I Depth SUMPS Ll Distance to nearest: DISPOSAL PONDS ❑ Well Foundation Method of Disposal Property Line Property Line Number Property Line 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 call for all required inspections. Complete drawing on reverse side. Signed x purdancePrAleA Drilling Corp. Title: Date: FOR DEPARTMENT USE ONLY Application Accepted by Date Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 Q Manteca 623-7104 ❑ Tracy 835-6385 Applicant - Return all c oas tto nvironmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 A A—1 t EH 13-241REV. I/Ha EH 14-26 FEE INFO AMOUNT DUE AMOUNT REMITTED CK CASH RECEIVED BY DATE PERMITNO. +� r7� (W— J r