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APPLICATION FOR PERMIT 4 SAN JOAQUIN LOCAL HEALTH DISTRICT , 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 Colpv PERMIT EXPIRES TYEAR FROM DATE ISSUED VM? P U e-• (Complete in Triplicate) �P�jN Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein de rlflT�tion is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules erttl� +or, an Joaquin Local Health District. f�N F Job Address 14900 W. Hwy. 12 city Terminous Lot Size PM 14900 W Hwy. 12 Owner's Name MR. Steve Woodward Ad&ew Terminous, CA 95240 phone (209) 369-1041 P.O. Box 535 Contractor ASE Drilling Address San Ramon, CA 94583 License No C57-487000 Phone 415 820-11350 TYPE OF WELL/PUMP: NEW WELL O WELL REPLACEMENT ❑ DESTRUCTION O PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER J§ 6 soil borings 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 O Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia.of Well Casing 4 O Domestic/Private ❑ Gravel Pack ❑Tracy Type of Casing Specifications Fl Public Fl Other n Delta Depth of Grout Seal Type of Grout I 1 Irrigation —.Approx. Depth I I Eastern Surface Seal Installed by _ Repair Work Done ❑ Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material Itop 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION l I DESTRUCTION I 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 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 Ll 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 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 applicant st call for all re wired inspections. Complete drawing on reverse side_. 1 / y f1 Signed X\ J Title: iIJ l�!'rG111'Y/C'Y7JK a{ � Date: / F D A T USE ONLY Application Accepted by Date /' Area Pit or Grout Inspect Date Final Inspection by Date Additional Comments O Stk 466-6781 odi 369- Manteca -7104 10 i4acy 835-6385 QO Applicant- Return all copies to: Environmental Health Permit/Services,1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH CK 0 RECEIVED BY DATE PERMIT'NO. • EM 1124 IREV.1 i n s) EH 14-2a