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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone 12091 466-6781 • PERMIT EXPIRES 1`YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District fora 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-tor well/pump and the Rules and Regulations of the San Joaquin Local Health District. 224 I�! IST CT,ETr i S City aTJEI iIIIITS Lot Size 20 ac PM Job Address _ Owner's Name'GMGZ TS vli Address � -o T IT �' Y Phone 473. 8643 Contractor T'El GROSS Addess P B� 8 GNense No377�-"..—Phone _ _ TYPE OF WELL/PUMP: NEW WELL � WELL REPLACEMENT ❑ DESTRUCTION El . - - ""`•PUMP INSTALLATION" SYSTEM€REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES ; DISPOSAL FLD. PROP. LINE -2-US), AGRICULTURE WELD OTHER WELL PITS/SUMPS FOUNDATION 1 >! i INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIORS 8- ❑ kndustriai LAJ ❑ Open Bottom ❑ Manteca Dia. _. Well Excavation h Dia. of Well Casing Domestic/ &Gravel Pack �. ❑ Tracy Type of Casing h Public s ue0' Specifications t fl Other 'F,. Delta Depth of'Grout Seal Type of Grout - 11 Irrigation _Approx. Depth L VEastern Surface Seal Installed by CC)TIR 1 Q 1OR � Repair Work Dane ❑ Type of Pump - ? - 3 H•P• _ l State Work Done_ (� Well Destruction ❑ Well Diameter Scaling Material (tbp 50`1 1 R. Depth-` ' Filer Material (Below 50') # TYPE OF SEPTIC WORK: NEW INSTALLATION I:! -REPAIRlAODITION E I' €No septic system permitted if public DESTRUCTION I 1 sewer is } available within 200 feet.) Installation will serve: Residence 1 CommercialOther # { F' Number of living units: Number of bedrooms i Character of soil to a depth of 3 feet: _i 3 Water table depth 1 4 SEPTIC TANK ❑ Type/Mfg 'Capacity No. Compartments s ' Method of Disposal ' PKG. TREATMENT PLT. ❑ f { Distance to nearest: Well Foundation Property Line ! LEACHING LINE ❑ No. & Length of lines i Total length/size FILTER BED ❑ Distance to`nearest: Well Foundation Property Line t r Number € SEEPAGE PITS €'I Depth Size E SUMPS ❑ Distance to nearest: Well Foundation Property Line a.DISPOSAL)PONDS ❑ 16! r----_..� -- I hereby certify-that•I have"prepa�ad"this`a"pplicet'ion aand-that the work will'be-t6iie m accordance with San Joaquin county ordinances, stare laws;,and rules and regulations of the San Joaquin Local Health Diltrict. ! Home owner or licensed agent's signature certifies the following: "I certify thatJh�the,performance.of the work'fo`wliich this permit is issued,'l shall not employ any person in such manner as to become subject to workman's compensation lawls 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`pei rsons.subject to workman's compensa- tion laws of California." t r The applicant must call for all equirJ inspections. Complete drawing on reverse side. Signed X Title: tC Data: 1-2»89 4 FOR DEPARTMENT USE ONLY Date I ^ .--4 1 Area ` Application Accepted by o EtData g�g 4� Final Inspection by Date I Pit or Grout Inspection by F � i Additional Comments: '` r ❑ Stk 466-6781 El Lodi' 369-3621 El Manteca 823-7104 ❑ Tracy 835 6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009,Stk., CA 95201 FEE AMOUNT DUE �� IAMOUNT REMITTED C K R RECEIVED BY DATE PERMIT"N0. INFO k ♦.EH13-244REV.ri95) �S� `}/Q�� ( EH 14-2a lei