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APPLICATION FOR PERMIT t SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 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 wel!lpump and the Rules and Regulations of the San Joaquin Local Health District. Job Address 1.1161. N. Highway 99 City Zodi Lot Size PM Wilfred Forbes Address 11161 N. Highway 99 Phone 3696398 Owner's Name 1 Talk Well Address 202�F E Charter Way License No. 371560 Phone 4b2-7676 Contractor TYPE OF WELL/PUMP:. NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ # t-r PUMP INSTALLATION IT SYSTEM REPAIR ❑ OTHER ❑ _ r DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE �" TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS E7 Industrial ❑ OpemBdttom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing N Domestic/Private',ry 1-1 Gravel Pack El Tracy Type of Casing Specifications ' J- �. Type of Grout - f l Public } ea 1-1 Other Ll Delta Depth of Grout Seal i r.r _,Approx. Depth I i Eastern 5 rface Seal Installed by 111rrigation p Installed Repair Work Done ❑ Type of Pump sub H.P. 1. 2 State Work Done Well Destruction , ❑ Well Diameter Sealing Material (top 50'1 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIR/ADDITION I i DESTRUCTION I ),(No septic system permitted if public sewer is ! ;available within 200 feet.i Installation will serve: I Residence Commercial Other±.1! I � t �. Number of living units: a ,Number of,bedrooms _ character sof soil io a depth df 3 feel: -— � . Water table depth v r4 . SEPTIC TANK ❑ Type/Mfg f" Capacityt " No. Compartments PKG. TREATMENT PLT, ❑ • ,, s ,f Method of Disposal f Distance to nearest: Well Foundation Property Line F I LEACHING LINE 171 No. & Length of lines Total length/size t t ,r FILTER BED El Distance to nearest: Well ��Foun_dation Property Line lI, SEEPAGE PITS + I 1 DeptSize Numberh SUMPS LlDistance'to nearest: Well Foundation Property Line DISPOSAL PONDS' t❑ ` I 9 1D i 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 r lations of the San Joaquin Local Health DiMrict. Home ow r 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 an pe on in su n er as to bec a subjec to workman's compensation laws of California."Contractor's hiring or sub contracting signature certifies th foll ing: " certify hat in a mance the work for which this permit is issued, I shall employ persons subject to workman's compensa t tion laws o al rnia." The applicant st al r I 'red 'n t' nA. co plete draw on reverse side. Signed X Title: sec-Tres Date: 22 Mar 90 OR DEPARTMENT USE OfULY_° Application Accepted by Date Z Area rCa Date Pit or Grout Inspection by Date Final Inspection by_— - Additional Comments: ❑ Stk 466-6781 ' ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-3385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DVE AMOUNT REMITTED CASH RECEIVED BY PATE PERMIT'ND. r INFO �r �� ♦ EH 13-24(REV.1/x sl 9l.J !V — L EH i4-ZB i