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r i'"' •' APPLICATION. FOR PERMIT Y <br /> SAN JOAQUIN LOCAL HEALTH,DISTRICT �Q <br /> �.. 1601 E. HAZE' TON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 ; <br /> PERMIT EXPIRES 1 YIEAA PhOM DATE ISSUED, <br /> (Complete in Triplicate) <br /> 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 <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rule's and Regutations of the San Joaquin <br /> Local Health District. ? <br /> t�• <br /> Job Address 17777 R . r Tn,±RTY RD v City_GALT Lot Size PM <br /> Owner's Name PACIFIC COAST FARMS Address P.0.10_00 HUGHSON; CA Phone e — <br /> Contractor PURVIANCE DRILLEIAFleeR4C P.O.64 LINDEN License No. 372923 Phone887-35-94 <br /> TYPE OF WELL/PUMP: NEW WELL 9 WELL REPLACEMENT ❑ DESTRUCTION ❑ r <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Y <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE g <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS it <br /> C7 Industrial ❑ Open Bottom Cl Manteca Dia. of Well Excavation " Dia. of Well Casing ? j"" +? <br /> a <br /> 11 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing STFEIL Specification?; <br /> V1 Public X Other fl Delta Depth of Grout Seal 0° Type of Grout" <br /> N Irrigation ???700dpptox. Depth I I Eastern Surface Seat Installed by <br /> Repair Work Done U Type of Pump H.P. State Work Done_ '( <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> Depth Filler Material (Below 50'1 _ <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION l 1 REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is -^ <br /> Available Willihi 200 feet.) <br /> Installation wilt serve: Residence_ Commercial Other <br /> Number of living units:. Number of bedrooms <br /> Character of soli to a depth of 3 feet: Watef table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Camp6rtm9nts <br /> PKG. TREATMENT PLT, 0 Method of Disposal r <br /> Distance to neatest: Well Foundation Prbperfy Line <br /> LEACHING LINE ❑ No. & Length of lines a t� <br /> 9 Total length/size } <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line ! <br /> SEEPAGE PITS i I Depth Size Number <br /> SUMPS Ll Distance to nearest: Well Foundation — Property Line �•} fir, <br /> DISPOSAL PONDS ❑ ) <br /> I hereby certify that t have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin Local Health Di§trict, <br /> Home owner or licensed agent's signature certifies the following- r <br /> g g g: "I certify that in the performance of the work for which This perms!Is issued, I shall not � <br /> employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> 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 cdrilpensa- <br /> lion laws of California." <br /> The a licant m t call for a quir inspection4. Co€nplete drawing on r verse side. <br /> Signed Title: <br /> Dater d <br /> FOR DEPARTMENT USE ONLY <br /> Applicatio Accepted by Date Area"z�✓ `ti <br /> Pit or au nspection by— t C' Data C�Final Inspection by ate <br /> J �� <br /> Additional Comments: <br /> C3 Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823.7104 ❑ Tracy 635-6385 Cpr, a,rt- 6y-7J .5 e, <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> lFEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMI-r'NO. <br /> EH 1321[REV.t i n 5r <br /> EH 14-20 '—/ <br /> r <br />