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APPLICATION FOR PERMIT SANG A IN LQCABL HEALTH DISTRICT -rbvr Er o�ic vE. , STOCKTON, CAI r Telephone (209) 4666 8} 468 - D338 PERMIT EXPIRES 11YEAR 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.. 18 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. ✓ Ill CSf3,r'� �D LOyI.Yj HccyYJ✓ rY,�y � /�f� C�S�''d "-�6P.s. Job AA`d'd�7ressrs AreaL Surrounding 749 ockt EE . �.fCj dartaer Waryry Stockton Lot Size PM Owner's Name DarDetro . Inc . Address 3450 El Camino , Ceres , Ca . Phone 209 537 - 077 Contractor Pierson Drillinla Address611 S . 9th St . , Modest@icenseNo614108 Phone( 209 ) 545 - 2 338 TYPE OF WELL/PUMP: NEW WELL IX WELL REPLACEMENT ❑ DESTRUCTION ❑ _ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES 20 ' DISPOSAL FLD. PROP. LINE 10 1 FOUNDATION AGRICULTURE WELL OTHER WELL 62 t PITS/ SUMPS INTENDED USE TYPE OF WELL PROBLENkAREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation 8 Dia. of Well Casing 2 " ❑ Domestic/ Private ❑ Gravel Pack ❑ Tracy Type of Casing PVC SCh 40 Specifications M Public ❑ Other ❑ Delta Depth of Grout Seal 46Type of Grout Cement I I Irrigation —Approx. Depth I I Eastern Surface Seal Installed by Pierson 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 Il REPAIR /ADDITION I I DESTRUCTION ( I (No 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 +(� l 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 Line 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 Dilarict. 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, Ishall n employ any person in such manner as to become subject to workman's compensation laws of California. " Contractor's hiring or sub-contracting sI natu 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 applicant rppst ca or all t( Gired inspections. Complete drawing on reverse side, i- ---- Signed // Title: President Date: 3 / 15 / 94 F DEPARTMENT USE ONLY �� Application Accepted by Date Area Pit or Grout Inspection by DateFinal Inspection by Data Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca a23-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. B 2009, CA 520 O ?A 9 INFO AMOUNT DUE AMOUNT REMITTED CASH RE RECEEIIIVfED BY DATE PERMMIT NO. �. EH 13-24 (REV. i / x510� � /]/ �y '7,}( „`/ �2 73 'wl EH 11-M // L/�V C/ L I