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�1 APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELi ON AVE., STOCKTON, CA Telephone (209) 466-6781 t PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application 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 j 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 9 City �7 i�A.) Lotlsize AG. PM Owner's Name 1ZtW A 1-h 11. R U A ZZ Address _ 51%�F Phone Contractor's Name x. 4/01.7A License No._ ",�2!!::2 Phone a"3 `` TYPE OF WELL/PUMP: NEW WELL ❑ '..,y r WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ _ SYSTEM REPAIR ❑ OTHER ❑ G' DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES' DISPOSAL FLD. PROP. LINE FOUNDATION""`"''° 'AGRICULTURE WELL OTHER WELL PITS/SUMPS `n INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia-of Well Excavation Dia. of Well,Casing 4 Ell Domestic/Private ❑ Gravel Pack ❑Tracy Type of Casing Specifications, j S 9 ., Ll Depth of Grout Seal LI Public ❑ Other p Type of Grout ❑ Irrigation ---Approx. Depth :❑ Eastern Surface Seal Installed by ! Repair Work Done ❑ Type of Pump H.P. State Work Done Well ❑ Well Diameter Sealing Material (top 501 (�} ;. Depth Filler Material (Below 501 / TYPE OF SEPTIC WORK: NEW INSTAL-LA-TION--OP'-REPAIR/ADDITION❑ DESTRUCTION ❑ (No septic system permitted if public sewer is r i r` +., - � available within 200 feet.) " t Installation will serve: Residence_ Commercial_ Other Number of living units: __L_ Number of bedrooms Character of soil to a depthh f 3 feet: Water table depth SEPTIC TANK L�7 TypelMfg Capacity 12-49-0 No. Compartments A PKG. TREATMENT PLT. C1 Method of Disposal Distance to-nearest:...,,....Well_"Foundation 192 Property Line J (� LEACHING LINE No. & Length o�flnes; _ '_~ �S� Total length/size y FILTER BED ❑ Distance to nearest: Well 71' Foundation 30` Property Line /D SEEPAGE PITS Depth 7-Si Size 3 `� Number SUMPS ❑ Distance to nearest: Well '100 Foundation_..._-._ Property Line AI 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."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,I shall employ persons subject to workman's compensa- tion laws of California." The applicant.must call for all required inspections. Complete drawing on reverse side. Signed 6Z Z4 Title: Date: 2- 9 8., FOR DEPARTMENT USE ONLY Application Accepted by : Date Area t o Grout Inspection by'' �ate 1-ILA35� Final Inspection by�?�-� Date 9-I -b 5 Additional Comments: ❑ Stk 466-6761 ❑ Lodi'. 369„3621 Manteca 823-7104 _ ❑ Tracy 835-6385_ Applicant- Return all copies to: Environmental Health Pmit er /Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 �4 FEE AMOUNT DUE AMOUNT REMITTED CK ,r RECEIVED BY DATE PERMIT'NO. INFO CASH' _ i EH 13-24(REV.10163) "' 5 * 1 til q c1 EH 1126