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y 1 APPLICATION FOR PERMIT , SAN JOAQUIN LOCAL HEALTH DISTRICT x 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 V PERMIT EXPIRES TYEAR 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 he describrt*,kTh1s cation is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and art Joaquin Local Health District. Job Address 14900 W. Hwy. 12 City Terminous Lot Size PM -, 14900 W Hwy. 12 Owner's Name MR. Steve Woodward Address Termirious, CA 95240 Phone (209) 369-1041 P.O. Box 535 I Contractor ASE Drilling Address San Ramon, CA 94583 License No.C57-487000 Phone (415) 820-1850 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT O DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR O OTHER 9 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 F ❑ Industrial n Open Bottom ❑ Manteca Dia. of Well Excavation Dia.of Wel!Casing Q ,❑ Domestic/Private ❑ Gravel Pack Q Tracy Type of Casing Specifications 171 Public 11 Other M Delta Depth of Grout Seal Type of Grout I I Irrigation —Approx. Depth I i Eastern Surface Seal installed by _ Repair Work Done 47 Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material {top 50'1 I Depth Filler Malarial (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITiON I I 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 11Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT.❑ Method of Disposal Distance to nearest; Well Foundation Property tine e' LEACHING LINE ❑ No. & Length of lines Total length/size r FILTER BLED ❑ Distance to nearest: ' Well Foundation Property Line f SEEPAGE PITS I I Depth Size Number E SUMPS 0 Distance to nearest: Well Foundation Property Line !! DISPOSAL PONDS ❑ _ I, I hereby cerify 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 parson in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or subcontracting 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 Califomia," The applicant st call for all re wired inspections. Complete drawing on reverse side. Signed X Title: ra L Yi .l f Y�/�`la[IIl1 Date- F D USE ONLY il Application Accepted by Z Date ' Area I Pit or Grout Inspect �/t/ pate o Final Inspection by Date , Additional Commonts ' r ( Cl Silk 466-8761 odl 369-36ZY Manteca -71 D4 10 Tracy 835-=5 i Applicant- Retum all copies to: Environmental Health Permit/Services 1601 E. Hazelton Avg., P.Q. Box 2009, Stk., CA 95201FEE r )NFO AMOUNT DUE AMOUNT REMITTED K H RECEIVED BY DATE PERMITNO, 1 _ i13 24 EH 1428 EH M26(REV.k/95Y CJ 1