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APPLICATION FOR PERMIT F� SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE„ STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES T YEAR FROM DATE ISSUED (Complete in Triplicate) Application is"hereby made to the San Joaquin Local Health Dislacl•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. Job Address 14900 W. Hwy 12 City Term no Lot Size pM i Owner's Name Steve Woodard Address 149000_ W Ewy,_12, T e,rrninrnrsx,CAphone I Contractor Aqua Science EnAineer8ddress PO- Box 535 -San Ramon License No. Ohone4ls-820 C)19 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ ( PUMP INSTALLATION M SYSTEM REPAIR ❑ OTHER NK Soil borings DISTANCE TO NEAREST; SEPTIC TANK SEWER LINES DISPOSAL FLD:' PROP. LINE i .111 FOUNDATION-- AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS i It Cl Industrial ❑ Open Bottom ❑ Manteca Dia- of Well Excavation ` I Qia. of Well Casing CI Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications neat cement S l l" M Public n Other FI Delta Depth of Grout Seal Type of Groutbentonite S ,I I I irrigation _.Approx. Depth I I Eastern Surface Seal Installed by .i Repair Work Done ❑ Type of Pump H.P. State Work Done _ Well Destruction 0 Well Diameter Sealing Material (top 501 neat cement/be � bent 15 feet Depth Filter Material (Below 50'1 d TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I 1 DESTRUCTION I. I (No septic system permitted if public sewer is „.- available within 200 feet.) Ins[allatidn will SeiVn:"Residehce'- — "rCbmmercial =-- Other` ��"" �–� �r��■iu*w �.k� rtr. Number of living unit's: Number of bedrooms ` Character of soil to a depth of 3"feet; Water table depth t SEPTIC TANK ❑ Type/Mfg Ca cit p Pa y No. Compartments PKG.TREATMENT PLT.❑ Method of Disposal II' Distance to nearest: Well Foundation Property Line t LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED 0 Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size ` Number SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ - r a 1 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 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 8PpI1caaLP5R call for all r lied inspections. Complete drawing on reverse side. 11 Signed «— Title: Environmental Specialist pate; 8-17-8$„ F EPARTMENT USE ONLY - `i JJ 1 •Applicallon,Accepted by Date Z;1 Area Pit or Grout Inspection by Data Final Inspection by-91 Date 1 f Additional Comments: ,j ID Stk `466-67131 0 Lodi 369-3621 ❑ Manteca 823-7104 0 Tracy 635-6385 Appli nt- Return all copse to: Environmental Health Permit/Services 16601 E. Hazelton Ave., P.O. Box 2009, Stk.,CA 851201 y rl fA� k'P� aster Z>D ;I I■■ I FEE AMOU INFO FEE NT DUE AMOUNT REMITTED ASH RECEIVED BY DATE PERMIT NO. i .CH 134R 1 fEy.111451 EH 7�-�9 4