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APPLICATION FOR PERMIT SAN JOAOUIN LOCAL HEALTH DISTRICT ` 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PAYMENT PERMIT EXPIRES 1'YEAR FROM DATE ISSUED RECEIVED (Complete in Triplicate) r. Application is he,eby made to the San Joaquin Local Health District for a permit to construct and/or install the worl!C erl inLs�'fi15A. This application is made in cor_pliance uyith SankJoaquin Country OrdinanceNo 549 for sewage or No. 1862 for well/pump and tI%ANI Q&Nj(a!�}Inf,+at►ithe San Joaquin Local,Ifealth f]istnctt t 1;n{ 'FSkk� ' �r p f ry ' cb% ;. PUBLIC HEALTH r H �, .. .. K w.=. ENVVRONMENTAL MEAL t i.u+'�ialt N ti 3:151 rS Kasson Rd ' ' 'E City Tracy Lot Size PM Job,Address,`` p Owner's Name Steve Ormonde Ormonde DeVAddress P.O. Phone 835,4949- Contractor gain- as B S. Address License No._2CLO 4 Phone 645 1185 TYPE OF WELL/PUMP: II NEW WELLXX WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK 100' SEWER LINES DISPOSAL FLD. 100' PROP. LINE FOUhNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA- CONSTRUCTION SPECIFICATIONS r fj r, ❑ Industrial ❑ Open Bottom. ❑ Manteca Dia. of Well Excavation ia. of Well Casing 4 C Domestic/Private [X Gravel Pack [NI Tracy Type of Casing PVC Specifications 1-1Public 171 Other ❑ Delta Depth of Grout Seal 100t Type of Grout Bentonite I I Irrigation 11Approx. Depth I 1 Eastern Surface Seal Installed by driller _ Repair Work Done 171Typen'i of Pump H.P. State Work Done Well Destruction ❑ We111Diameter Sealing Material Itop 50'1 Depth Filler Material IBelow 50') TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is 'I available within 200 feet.) Installation will serve:_Residence Commercial_ Other I Number of living units: :il Number of bedrooms Cy Water table depth Character of soil to a depth of 3 feet: P SEPTIC TANK d Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ II Method of Disposal { Distance to nearest: Well Foundation Property Line 11 LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation_ Property Line 0 SEEPAGE PITS I I Depth Size Number SUMPS - _.T Ll ,-Distance to nearest: Well YFoundationProperty Line t . DISPOSAL PONDS El _._ .. �=.• _ _. 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, 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 all,required inspections. Compiete drawing n rev r it 10-27•-89 Signed X Bros. B Titl - Date: PEP MEWT USE ONLY 9 / Application Accepted by Date rArea 2le Pit or Grout Inspection by Date Final Inspection by e Additional Comments: ❑ Silk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies tri: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 tz Il FEE AMOUNT DUE AMOUNT REMITTED r K RECEIVED 8Y DATE PERMIT ND. INFO ♦.EH13-241REV.,/R51 IZ0`00 30 . �� "'� j-2b , EH 14-2a 7