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APPLICATION FOR PERMI'� v SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Applicin ation 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 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. Hyy 12 City Terminous Lot Size PM Owner's Name Steve Woodard Address 14900 W • Hwy 12 Phone Contractor Aqua Science Engine er,Qddress PO Box 535 San Ramon TYPE OF WELL/PUMP: License No. 487000((' 7I)hone NEW WELL ❑ WELL REPLACEMENT ❑ PUMP INSTALLATION ❑ DESTRUCTION ❑ 6 DISTANCE TO NEAREST: SEPTIC TANK SYSTEM REPAIR El U soil borings I SEWER LINES DISPOSAL FLD. FOUNDATION AGRICULTURE WELL PROP. LINE INTENDED USE OTHER WELL PITS/S TYPE OF UMPS _ WELL PROBLEM AREA CONSTRUCTION ❑ Industrial ❑ Open Bottom ------ SPECIFICATIONS ❑ Manteca Dia. of Well Excavation n Domestic/Private L1Gravel Pack Dia. of Well Casing O Tracy Type of Casing F) Public f-1 Other n Delta Depth of Grout Specifications neat cement/I I Irrigation Approxi Seal Depth I I Eastern Type of Groutbentonite Repair Work Done El Type of Pump H.P. Surface Seal Installed by __ Well Destruction ❑ Well Diameter State Work Done_ Sealing Material (top 50') neat cement bentonite Slurry TYPDepth 15 feet Filler Material (Below 50') bent E OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is Installation will serve: Residence._ Commercial_ Other available within 200 feet.) Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: SEPTIC TANK ❑ Type/Mfg Water table depth PKG. TREATMENT PLT. ❑ Capacity _ No. Compartments Distance to nearest: WellMethod of Disposal ---__ Foundation Property Line LEACHING LINE ❑ No. & Length of lines _ FILTER BED ❑ Distance to nearest: WellTotal length/size Foundation _ Property Line SEEPAGE PITS 1 I Depth SUMPS Size Number Ll Distance to nearest: Well DISPOSAL PONDS El Foundation Property Line 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."Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the to tion laws of California." Performance of the work for which this permit is issued,1 shall employ Persons subject to workman's compensa- The applican call for all r ed inspections. Complete drawing on reverse side. Signed X Title: Environmental Specialist Date: 8-17-88 F EPARTMENT USE ONLY Application Accepted by Date Sr Z3/� Pit or Grout Ins Area Inspection by Date -----_ Final Inspection by Additional Comments: Date ❑ Stk 466-6781 ❑ Lodi 369.3621 ❑ Manteca 823-7104 y p Tracy 835 6385 Applnt - Return all copie to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box Y009 Stk., CA 95201 d-%:+ed ?A, � 11 YY (' FEE &rS ^4 �.►. 'kd TfI t�`•r m INFO AMOUNT DUE AMOUNT REMITTED ASN RECEIVED BY DATE . EH 13N(REV.ii n 51 ?r - PERMIT NO.