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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES TYEAR 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.q . J J04:,. Job Address E. Liberty Rd. city Lockeford Lot Size 40a.C. PM Owner's Name Balas Const. Address 11900 Green Rd.WiltOn Ca. Phone 4$76040 Contractor Woods Well Drillxl res, 11944 Sir merhorn Rdticense No. 282866 Phone 745-2407 TYPE OF WELL/PUMP: NEW WELL Ot WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION Ek SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK 150 , SEWER LINES 150' DISPOSAL FLD. PROP. LINE _O 100 , FOUNDATION A00 t AGRICULTURE WELL OTHER WEL! PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 11Industrial X Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing tt X Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Steel' Specifications ]* 12 Ga. M Public f 1 Other F1 Delta Depth of Grout Seal 50 Type of Grout SaiY[l� Celli 't I I Irrigation --Approx. Depth I I Eastern Surface Seal Installed by Woods _ Repair Work pone ❑ Type of Pump SUB. H.p, 5 State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50'1 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION I 1 INo septic system permitted if public sewer is available within 2011 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 1� SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line �J LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line 1 SEEPAGE PITS I I Depth Size Number SUMPS ❑ 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. XZa 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, 1 shall employ persons subject to workman's compensa- tion laws of California." The applicant Tust call r a required inspections. Complete drawing on reverse side. Signed Title: Contractor pate: 1114/88 �R� `:.JOR(DEPARTMENT USE ONLY 1 C , Application Accepted by - M.-MON[`A-SkO. Date \-yA 1 y Area Pit or Grout Inspection by bate 17,� Final Inspection by Z,OV2x Date Y r Additional Comments: ❑ Stk 466-6781 ❑ L i 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 INFO AMOUNT DUE AMOUNT REMITTED CCK RECEIVED BY DATE PERMIT'NO. + EH 13-24(REV.tim51 I(/f'� �[' /J�� EH 14-26 [ O Y if v 1