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APPLICATION FOR PERMIT J0 A N JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELFON 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'Ofstr' t. I G-AsTer I �, ��o S�IP—E IK7 CSha,rl�e �Irmy De-oDea T nthron Lot Sae 800 AC PM Job Address city Owner's Name MIG '',nt erpri.SeS INC - Address 195 E T•Iorfran St. Phone 209-5 Perris , Calif. 92370 ContractorTorth Valley Drill ssInC. P.O . dox 108 License No. 4 ]-8834 Phone 16-8 —0 62 TYPE OF WELL/PUMP: NEW WELL ❑ L DESTRUCTION ❑ /�� PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER fJ No 1t z well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE _ l2 r`1 FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS 3 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom � Manteca Dia. of Well Excavation 011 Dia. of Well Casing 4tf ❑ Domestic/Private Q7Gravel Pack ❑ Tracy Type of Casing SCh 40 PVC: Specifications FI Public ❑ Other 177 Delta Depth of Grout Seal V2ri.--OUS Type of Grout T•Trat (`eme t I I Irrigation VdI7Approx. Depth I I Eastern Surface Seat Installed by C:Rm(?Tlt _ Repair Work Done ❑ Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material (top 50') Monitoring Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I INo 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 LEACHING LINE ❑ No. 8 Length of lines Total length/size FILTER BED Ll Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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 Di3trict. 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, 1 shall not employ any person in 98th 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 applica must call f r all requir d inspections. Complete drawin n r versa side. 1 ') Signed X Titl Date: 3 FOR DE ARTMENT USE ONLY ;;11 Application Accepted by / I Date Pit or Grout Inspection by.j Dat (Final Inspection b Date Additional Comments: " ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ 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 INFO AMOUNT DUE AMOUNpT-24 CASH RECEIVED BY DATE PER/MIIT('�NO. S EH 1314 IREV.1/x51 � I� 2 L,J 3)5/„O oi1X EH 1419 Uf./ 1 V