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J APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE.TON AVE., STOCKTON, CA Telephone 12091 466-6781 PERMIT EXPIRES TYEAR FROM DATE ISSUED (Complete in Triplicate) 2S— op-o—D Z I i 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 welllpump and the Rules and Regulations of the San Joaquin Local Health District.1,t1 Job Address S —see MAP City Lot Size PM CGG American services 505 Ctnumnity Lane Woodland Ca. 95695 Owner's Name kAddress Phone jll�Contract Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION D - PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE I FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS ; INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS i ❑ Industrial ❑ Open Bottom (7 Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications f') Public Cl Other ❑ Delta Depth of Grout Seal Type of Grout _ I I Irrigation —.-Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump N.P. State Work Doneee _ Well Destruction ❑ Well Diameter Sealing Material atop 50')Well Depth 51 Filler Material (Below 50'1 TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIR/ADDITION i I DESTRUCTION l I (No septic system permitted,if public sewer is available within 200 feet.) Installation will e: Residence— Commercial_ Other l' Number of living units. Number of bedrooms i Character of soil to a depth feet: ter table depth SEPTIC TANK ❑ Type/M Capacity No. Compartments II i PKG. TREATMENT PLT. ❑ Method of Disposal i Distance to nearest: oundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to st: Well Foundation Property Line SEEPAGE PITS epth Size _ Number SUMPS Ll Distance to nearest: Well Foundation Property e 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 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."Contractors hiring or sub-contracting signature certifies th ing: "I certify th performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion la of CalNifo ia." The a licant mus call f r equired i ctians. Complate drawing on reverse side. Signed x Title: Permit Agent Date: Sept. 28 1988 FOR DEPARTMENT USE ONLY �p Application Accepted by ` W Date �a Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 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 IFEE NFO AMOUNT DUE AMOUNT REMITTED CASH Ci' RECEIVED 6Y ©ATE PERMIT N0. {M k 1 W EH 14-26 "��44