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Ld APPLICATION FOR PERMIT V SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES t 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. s•, Oyer Ivy _t) - Parcel 25 & t8 , Corner of Acampo Lot Size 24 acres PM Job Address City Owner's Name hlamina Tnyes*mPni-C Address: 60 " Smith Mark-Pt C}rart . Phone c/o Hose, Fenton , Jones & Appel Inc. ; San Jose , CA 95113-2396 465-8712 Contractor ss 82� E. M rile St . License No. 1,12268 Phone TYPE OF WELL/PUMP: NEW WELL ❑ RE CE OF Ell Shallow bort igs PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ - OTHER 112 t0 10 feet de p i DISTANCE TO NEAREST: SEPTIC TANK _N ZA __ SEWER LINES _..N ZAr_ DISPOSAL FLD.Ti� PROP. LINE FOUNDATION M _A AGRICULTURE WELL N,(A OTHER WELL nJA PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS p. ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing A ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing N/A Specifications ❑ Public [K,Otth��errS011 ❑ Delta Depth of Grout Seal 1 _7 feet Type of Grout. Ch i Ps ❑ Irrigation 2—LOSa Rar ❑ Eastern Surface Seal Installed 6y � Repair Work Done ❑ Type of Pump - H.P. State Work Done Well Destruction ❑ Well Diameter 2 iNSA Sealing Material (top 501 a Sam YPDenn7pth 1A'r'- '1 10 , Filler Material (Below 50 TE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (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. (C� LEACHING LINE ❑ " No. & Length of lines Total length/size \ FILTER BED Cl Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑� Depth Size. Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ - .\ I hereby certify that 1 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 call for all fequjoe5 inspections. Complete drawing on reverse side. Signed X L. Title: Date: F PART BE ONLY Application Accepted by Date,s?-- Z At 3 Pit or Grout Inspection by Date . Final Inspection b>j �- Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6185 j 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 RECEIVED BY DATE PERMIT'110, / INFO �:. 41REy.h,esl 0 / _ U� /y/3 /yT