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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DIST 1601 E. HAZELTON 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.S O QC-Jr� 2L. Job Address ;ha Zpe inny Depot City Tathr.4p— Lot Size Ra_Se PM Owner's Name U • s • Army Address 250 Za thr017 Rd. Phone 209-982-2097 P .G. Box 108 Contractor Rindanl Drillinh Address Corning, Calif . 960Z,1ense No. 601535 Phone916-824-01 2 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ t PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ;Extraction -4-TA cc: 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 ❑ Industrial ❑ Open Bottom Manteca Dia. of Well Excavation _ Dia. of Well Casing 8 5/8 ❑ Domestic/Private )P Gravel Pack El Tracy Type of Casing steel 156 Wall Specifications FI Public ❑ Other Cl Delta Depth of Grout Seal Varies Type of Grout 9 sac _ I I Irrigation Varle SApprox. Depth I I Eastern Surface Seal Installed by Idell cap _ Repair Work Done ❑ Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material (top 50') Extraction Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I 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 ❑ 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 ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS LI 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, 1 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 certity 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 <' .( Title: (0 Date: FOR DEPARTMENT USE ONLY 22 Application Accepted by Daze -3110 ) RJ Area f`45 J s � Pit or Grout Inspection by Date--3/31 Ie/3 mal Inspection Date 111611-3 y534� 4.5-7 ` 555 44481 C.Eii, 4&OAS, 4 5 4170 <F6lC u� yl3( Additional Comments: 'f"t -r'' t s-- �'�.. , -C }f 1 -fes r f ' ❑ Stk 466-6781 ❑ Lodi 3821 ❑ Mafiteca 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 S v FEE AMOUNT DUE AMOUNT REMITTED K H RECEIVED BY DATE PERMIT'NO. INFO �.EH tYIRLV,iix5� EH t4251e /