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i i rf I APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT t 1601 E. HAZE T ON AVE., STOCKTON, CA k Telephone (209) 466-6781 h PERMIT EXPIRES 1 YEAR 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. 95320 ,lob Address 17487 E. Lone Tree Rd. City Lot Size PM owner's NameAgriCulturel Industri%9dress- PC Q. BOX 1076 F Contra)toPuTMlaRceDdll6M WI11n9 Corp. Address Pe 0. Box 64 License No. 377923 Phone — TYPE OF WELL-/PUMP: NEW WELL.❑ „WELL REPLACEMENT,❑ DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER 0 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS i INTENDED USE TYPE OF,WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS k f ❑ Industrial LJOpen Bottdm ElManteca Dia. of Well Excavation Dia. of Well Casing C] Domestic/Private L1 Gravel Pack ElTracy Type of Casing Specifications F1 Public f Other ED Delta Depth of Grout Seal Type of Grout (� I I Irrigation __ApproIx. Depth l I Eastern Surface Seal Installed by +wur ti y� Repair Work Dane ❑ Type of Pump Turbine H.P._75 7S State Work Done1nstalling ewe Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth 150 Filler Material (Below 501 I TYPE OF SEPTIC WORK: NEW INSTALLATION I1 REPAIR/ADDITION I I DESTRUCTION l I INo septic system permitted if public sewer is available within 200 feet.) r Installation will serve: Residence Commercial— Other Number ot living u ber of bedrooms 'f Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg acity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal ' Distance to nearest: Well Foundation Prop e LEACHING LINE ❑ No. & Length of lines _ Total length/size i FILTER BED ElDistance to nearest: Well Foundation Property Line tl - SEEPAGE PITS l I Depth, Size Number SUMPS L1 Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ t 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 t 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 applica must call f r I r uired inspections. Complete drawing on reverse side. Signed Title: President Data: 7/24/87 FOR DEP RTMENT USE ONLY Application Accepted by _ Date �~ Area F Pit or Grout Inspection by Date Final Inspection by Dates Additional Comments: ❑ Stk 466-6781 l❑ Lodi 369-3621 ❑ Manteca 523-7104 ❑ Tracy 835-6386 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 I f FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. INFO CASH F r EH 53-24{REV.1/"51 EH 1429 f