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APPLICATION FOR PERMIT Q fir[ w SAN JOAQUIN LOCAL HEALTH DISTRICT EG x�. 1601.E. HAZEL T ON AVE., STOCKTON, CA Telepho'he (209) 466-6781 W', PERMIT EXPIRES 1 YEAR FROM DATE(I 'NNE (Complete in Triplicate) IA1 N0�`1�'�E 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. L-7. I-s Job Address city#99/OAKWOOD FARMS City STOCKTONLot Size 5 ACRES PM Owner's Name =" DALE RUSSEL Address 1237 SHAFER ST. MANTECA Phone 239-4757 Contractor IIEfVfVi CS- BROS_ DRILI—Address 3525 PELAN ALE MOD ESTO License No. Phone 5 4 5–118 5 TYPE OF WELLIPUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ _ PUMP INSTALLATION [I_ SYSTEM REPAIR ❑ OTHER ❑ Y DISTANCE TO NEAREST: .SEPTIC TANK NONE SEWER LINES NONF DISPOSAL FLO. PROP. LINE — .FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS + INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial C.Open Bottom ❑ Manteca Dia. of Well Excavation 1211 Dia. of Well Casing 6" JQ Domestic I Private LX Gravel'Pack ❑ Tracy Type of Casing_ .PVC Specifications r`1 Public (=1 Other ❑ Delta Depth of Grout Seat 50 1 Type of Grout_BENTONITE I I Irrigation --Approx. Depth I I Eastern Surface Seal Installed by H F NAI N G S R R O S_ DRILLING Repair Work Done ❑ Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I'] REPAIR/ADDITION I I DESTRUCTION I 1 INo 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 I I Depth Size Number SUMPS, ❑ Distance to nearest: Well _ Foundation Property one 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, an 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 drawing on reverse side. p�;�l �A t� 9 r iCiQs+ �l Signed X' m� u�� fitle: '—^-"'"� Date: OR DE RTMENT USE ONLY f'Application Accepted by __ // Date Area </ Pit or Grout Inspection by ` Date 10` Final Inspection by Date Additional Comments: Ape ❑ Silk 466-6781 ❑ Lodi 349-3621 ❑ 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 AMOUNT DUE AMOUNT REMITTED ASH RECEIVED BY DATE PERMIT NO. INFO +.EH1 3-24 MEV.Mis) EH 14-28 [!