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. ... l? � `Y • y� APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1.601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES i 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 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 sod CF'�&^ e--C 61 4 Cityot Size � 'ZI PM Owner's Name A!- t"raidy/TS Address �i S ` Phone gk L //�� sr //�� //��+� /7 44^ 490- 7 ps 33 y-x,17 Contractor i� i�/d0 AddresslKt_F)yx G _ License No. 7 3 Phone TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION _SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK YS'a SEWER LINES 1 DISPOSAL FLD. PROP. LINE r � FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS v l INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS a i Ll Industrial ❑ Open Bottom C1 Manteca Dia. of Well Excavation 10L Dia. of Well Casing �. Domestic/Private VGravel Pack ❑ Tracy Type of Casing S'Tc+L Specifications 40 ❑ Public ❑ Other ❑ Delta Depth of Grout Seal 51 Type of Grout (J ❑ Irrigation '^1(17 Approx. Depth ❑ Eastern Surface Seal Installed by ZfU Repair Work Done ❑ Type of Pump 5 +— H.P. & r 1 State Work Done 911110" C10, * CrBloc Well Destruction C7 Well Diameter Sealing Material (top 50') 511'0 F'-y� _'AVAO ' F Depth Filler Material y'Below.,50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is l t , _._- v _�: available within 200 feet.) Installation will serve: Residence_ Commercial_ Other` � Number of living units: Number of bedrooms k Character of soil'to a depth of 3 feet:_-- Water table depth SEPTIC TANK ❑ Type/Mfg �� / Capacity No. Compartments i PKG'TFIEATMEIVT.PLT. F1Method of Disposal's Distance to nearest: Well Foundation Property Line l LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth 17 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 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 Title: Date: s x FOR DEPARTMENT USE ONLY Li �. Application Accepted by j Date Area Pit or Grout Inspection by Date t Final Inspection by Date Additional Comments: } /1 tk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104' . F ❑ Tracyj 835-6385 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 RECEIVED BY DATE PERMIT"NO. + +SH 13-241REV.1/H51 - ILA EH 14-28 Q 'J /��