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!ork p]-a.n faxed to APPLICATION FOR PERMIT S.000 „1 none Ratliff SAN JOAQUIN LOCAL HEALTH DISTRICT 2-21--,0 by 31TOlte & ssoc . -) e Telephone Yenning 1601 E. HAZELTON AVE., STOCKTON, CA V Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) /or install the work . This cation is madlenticomphance wtrieby l'Irtlh Sanade o the Joaqum County Ordinance Joaquin lNto.District549 for sewage permit to 1862 for cweii/dpump and the Rules and IR Regulations of he San'Joaquin Local Health District. Job Address 1884-6 ;; k;TY 99 city Nodi Lot size 55 AC PM Victor -5`ine P00ifts Address P.O . Dox 147 Lodi, C.9.1 .95244ne 209-368-511 Owner's Name � Corning,Cal. 90021 ContractoaTorth Valley Drill obs Inc . P.O. BOX 108 License No. 418834 phone916-824-C1 2 TYPE OF WELL/PUMP: NEW WELL LJ WELL REPLACEMENT ❑ DESTRUCTION ❑ f+ionitoring PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER 8 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. -PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing n ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing SCh 40 PVC Specifications I.1 Public ❑ Other Ll Delta Depth of Grout Seal 10, Type of Grout igati come I I Irrigation 20t.Approx. Depth I I Eastern Surface Seal Installed by Ceinent _ Repair Work Done ❑ Type of Pump - H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 !!ionit Oring Depth Filler Material (Below 501 h1 TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION I I 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 r 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 t 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 Di%trict. Home owner or licensed agent's signature certifies the following: "I certify that in the pejformance 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,[.shall employ persons subject to workman's compensa- tion laws of California." J) The appli t must call for all requ' a `n (Sections. Complete drawing on 1�rrse�side, J/p Signed X Title: i•_ �/ Date: �— I 0 DEP ENT USE ONLY ` Application Accepted by Date �Zd' i Area Pit or Grout Inspection by `` / Date Final (Inspection by L Date Additional Comments: -z-fE 0— r�fitf r tC/ ✓ N// ! X% .Ai ❑ Stk 468-6781 Lodi odl 369-3621 LJ Manteca 823-7ld4 ❑ Tracy 835-6385 4— /1l d r r—ek �T Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2DD9, Silk., CA 95201 ` Yuru C 4�p FEEAMOUNT DUE AMOUNT flEMITTED RECEIVED BY DATE PERMIT'NO. /r INFO r + EK 1: (REV.lix5) p T, EH -28 O