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a. APPLICATION FOR PERMIT_.-: SAN JOAQUIN'LOCAL"HEALTH DISTRICT 1601 E. ,HAZE i ON AVE:, STOCKTON, CA ' Telephone (209) 466-6781" 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 I 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 City'i Sit/ Lat Size PM r r• sJ 4 J: J. ii Owner'sName Address 31 Phone Contractor �f/D Ayea-1> Address' ".S AJ- 4-//4L"AjU License No. ,Z .__Phone ltrd `3 g ;t TYPE OF WELL/PUMP: NEW WELL El -,WELL REPLACEMENT U. `t DESTRUCTION ❑ r 4 f PUMP INSTALLATION 171t`gJ -'SYSTEM REP41R CQ a :„ OTHER-12, �A titi4 . •tet$ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL Fib. PROP. LINE OUNDATION t AGRICULTURE-IWELL""'_"" "OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA°CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom-:? ID Manieca Dia. of Well-Excavation I Dia. of.Weil Casing 1:1Domestic/Private F1Gravel-,Pack D Tr�y T ype of Caging Specifications ❑ Public ❑ Other i ElDelta Depth of Grout Seal j Type of Grout ❑ Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by t Repair Work Done. ❑Type of-Piimp'^ ' H.P. r _ State_Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler'Material {Bela 501 * 3 1� vi TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ArVATION 'DESTRUCTION-❑ '(No septic system permitted if public sewer is 1 e' available within 200 feet.) Ini tallation will ser,/e: Residence_P/Commercial_(Other E 4• Number of living units:4— Number of bedrooms�. i t Character of soil to a depth of 3 feet: LAy k t a Water table depth SEPTIC TANK ❑ Type/Mfg �V►e77/A16 Capacity � No. Compartments � I f PKG. TREATMENT PLT:❑ .d ' Method of Disposal I f Distance to nearest Well Foundation property Line { LEACHING LINE O No. &.Length of lines r CT/A/6 I Total length/size {t FILTER BED ❑ Distance to nearest: Well 4 Foundfation iProperty Line i P y i _ SEEPAGE PITS epth id t Size �- [`Z�� __ Number I SUMPS LL7 Distad a>l-Dearest: Well Foundation- 7-0 ,Property Line -1 DISPOSAL PONDS ❑ ftr { heieby 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 shalt not i employ any person in such manner as to became subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature certifies the following: l,certify that in the performance of the work for which this permit is issued,I sliall employ persons subject to workman's compensa- 1 tion Flaws of California." Theapplicantmust call for all required inspections. Complete drawing on reverse side. p, Signed Title: ll - i Date: I s f OR DEPARTMENT USE ONLY j § ,t I ' Application Accepted by Date Areat Pit or Grout Inspection by ate `-`Final1'nspection R Date v �. Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 t Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE" ! "•IN O-" AMOUNT DUE_ �,.,.,.,.AMOUNL REMITTED,� CK �.r.REClEIVED-BY- * DATE PERMIT"NO, + EH13-24(REV.t/85Ir� kEHt4265 ��• © 'J --- `!l` "� / �� 5 US^�O10�