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i f APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA I, Telephone4209) 466-6781 PERMIT EXPIRES TYEAR FROM DATE ISSUED it • (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. e , II 13,653 B.. ahant Rd. City AG " ` �� of Size_ 5aCj: PM Job Address ., - _. owner's Name Joannie GaCheS Address 1442 Church St",LodisCa, Phone I �rGalt, Cantractor Woods Well nrilli�ress 11944 Simmerhorn LRDZicense No. 282866 Phone 745-2407 TYPE OF WELL/PUMP: NEW WELL (R. WELL REPLACEMENT 17 DESTRUCTION ❑ II PUMP INSTALLATION l SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK 150 SEWER LINES -150* DISPOSAL FLD. PROP. LINE FOUNDATION 80! AGRICULTURE WELL. OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS "Cl Industrial )1 Open Bottom [I Manteca Ria. of Well Excavation it tf Dia. of Well Casing rte-- , Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Steek.1�ga* Specifications 7l Public r Other ❑ Delta Depth of Grout Seal _ " 5[)t Type of Grout et � !I'] Irrigation 24n sc_Approx. Depth I I Eastern _ Surface Seal Installed by "Woods Well Drilling Repair Work Done ❑ Type-of Pump S11he H,P. State Work Done Well Destruction ❑ Well Diameter Sealing Material Stop 501 ,II Depth Filler Material (Below 501 ;TYPE OF SEPTIC WORK: NEW INSTALLATION (1 REPAIR/ADDITION (.I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.l Installation will serve: Residence_ "Commercial_ Other Number of living units: Number of bedrooms - i Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments a 'a PKG. TREATMENT PLT, 0 _ _ _ r Method of Disposal Distance to nearest: Well Foundation Property Line "LEACHING LINE ❑ No. & Length of lines Total length/size 'FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ('Ir Depth Size Number ,;SUMPS LlDistance to nearest: Well Foundation Property Line EISPOSAL PONDS ❑ ;il 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 .jIrules and regulations of the San Joaquin Local Health District. i 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 1 requir d inspections. Complete drawing on reverse side. ";Signed X — Title: Contractor Date: 11--12-87 I FOR DEPARTMENT USE ONLY �j f� /� IlApplication Accepted by Date I—)J : Area `-�( Pit or Grout Inspection by Date - Final Inspection by 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 FEE AMOUNT DUE AMOUNT REMITTEDCK RECEIVED BY DATE PERMIT NO. INFO 4y /y + EH It13-24(REV.r i H 51 EH 10-26 • II , q.