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' APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT PF-'(F &RF 1601 E. HAZEL i ON AVE., STOCKTON, CA .� Telephone d209) 466-6781 w ! PERMIT EXPIRES 1'YEAR FROM DATE ISSUED APR I h tD 21_._. �,a.,--.,. .► (Complete in Triplicate) ENVIROMENTAL }1 Application is hereby made to the San Jo in Local Health District for permit to construct and/or install the", h�rliry(vtg-se ih}g r plication is made in compliance with San Joaquin County Or mac No 549 for e�wag�e_Cw o0^186 for well/pump and the Rules and Reg�arb � he San Joaquin Local Health District. p1�54��i� Ile 7 �r""�° ''"' �� 0�J -f 20- 7 No ddress Av il.able ! Job Addressye City Lot Size PM— 0 Owner's Name 3 Oaks Vineyard- Address 21030 -. Davis Phone ! ContractorG®ehrina .121IMP—_ Address 1.7754 N. Hvy. 88 Licee No. 309031 Phone @ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION XJ SYSTEM REPAIR ❑ OTHER ❑ ' DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ! O Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑Tracy Type of,Casing Specifications "1 Public (:1 Other n Delta Depth of Grout Seal Type of Grout I I Irrigation —..Appfox. Depth I I Eastern Surface Seal Installed by - ! Repair Work Done ❑ Type of Pump Turbine H.P. 1 5 q State Work Done Well Destruction ❑ Well Diameter Sealing Mate.rial (top 501 Depth Filler Material (Below 501 '� ) ! TYPE OF SEPTIC WQRK:—NE-W4NSTAL4:ATI0N 1.,1 REPAIR)ADDITION I 1:1-DESTRUCTION-1 1 (No septic-system-permitaed it public sewer is ;y ,� #{ available within 200 feet.) D 1 installation will serve. -'Residence_:.=-Commercial Number of living units: Number of bedrooms �\`I Character of soil to a depth of 34eet: Y` a Water table depth Y \ SEPTIC TANK ❑ Type/Mfg ; Capacity No. Compartments PKG. TREATMENT PLT.❑ ;r" I 'Y,>/ r Method of Disposal Distance to nearest: ytr Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines a i''+`.;°.'i r Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line ! SEEPAGE PITS I I Depth Size Number SUMPS (_l Distance to nearest: Well Foundation Property Line "'`DISPOSAL PONDS ' ❑ - 0- ' • ._ ' 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. t 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 su manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature certifies the followin erfiffy that in the performance of the work for which this permit is issued,6 shall employ persons subject to workman's compensa- tion laws of C0.111 �ivreqw The applicantred inspections. Complete drawing on r er sidee. Date: 4_b 141TI,Title: �. ' 1IF FOR UEf"ARTMENT USE ONLY Application.accepted by � � �'� �� Date.� "�-�� Area ®C'_ ' Pit or Grout Inspection by Date Final Inspection b� ' ' ' ' Date Additional Comments: ❑ Stlt 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 a FEE A U UE AMOUNT REMITTED CASH RECEIVED BY DATE PERrM 'N0. INFO - ! EFI ta•a4laev.siriel + a� $-91 Ll EH'i4-28 I_