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w APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE i ON AVE., STOCKTON" CA Telephone (209) 466-6781 re PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 0 �„1eq,Q,aL y (Complete in Triplicate) JVO� P L,,,,, 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 Ryles and Regulations of the San Joaquin Local Health District. ' VERNALIS �.Q.S Job Address 37100 K O S T E R RD City Lot Size PM Owner's Name JERRY COSTA' Address P .O . BOX 1089 TRACY CA Phone 835-7229 Contractor HENNINGS BROS. DRILL.AddresF 3525 PELANDALE AVE. MOQ.icense No. 290813 Phone 545-1185 TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT;< DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK f 150 ' SEWER LINES -F 15 0 1 DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS II ^ 0 Industrial El Open Bottom El Manteca Dia. of Well Excavation Dia. of Wel! Casing QC Domestic/Private X7 Gravel Pack ❑ Tracy Type of Casing PVC 200 SCHEDIiLESpecifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal 50 , Type of Grout BENTONITE ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by H E N N I N G 5 BROS . DRILLING CO. \ Repair Work Done ❑ Type of Pump H.P. State Work Done SLAB BY OWNER [� Well Destruction ❑ Well Diameter Sealing Material (top 501 vC� Depth Filler Material (Below 501 �] TYPE 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 LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ 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 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 compens tion laws of California." The applicant must call for all required inspections. Complete drawin on revers side. Q • Title: Date: —��9 Signed -, f FOR DEPAR ENT E ONLY7. - Application Accepted by f/" Date —T�s Area O Pit or Grout Inspection by Date Fi I Ins coon by Date Additional Comments: YG t'. Q Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 . Hazelton Ave., P.O. Box 2009, Stk., CA 95201 J1 '1 FEE AMOUNT DUE AMOUNT REMITTEDOK RECEIVED BY DATE PERMIT`NO. INFO �^ yf + EH13-24MEV.1/aE7 c7p (Sl�(� ' ` gyp- �,S_}�� d EH 1426