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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA 1\ Telephone (209) 466-6781 l� 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 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 M 0*33- A AC/}�11maCity !_)C _ Lot Size 26. 2PM ., Owner's Name I ANCP RANe,Aress 311,1- #4nn SA l� T' hone --15- —461740 Contractor Address /y4�7 4Z �ill� Q?/_ License No. Phone'33 TYPE OF WELL/PUMP: NEW WEL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION�❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK s�, SEWER LINES /" DISPOSAL FLR,-' PROP. LINE FOUNDATION 'Q` AGRICULTURE WELL T�THER WELL --' PITS/SUMPS -� INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIO S ❑ Industrial rOpen Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing 'T46-0�� — Specifications . ('I Public ❑ Other ❑ Delta Depth of Grout Seal 10-0 Type of Grout—=E- .*__ _ _ ' Irrigation ..Approx. Depth l I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. Sta one_ Well Destruction ❑ Well Diam Sealing Material (top 50') Depth Filler Material (Below TYPE OF SEPTIC WORK: NEW INSTALLATION l 1 REPAIR/ADDITION l I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) 1 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: Foundation Property Line LEACHING LINE ❑ No. & Length of ' as Total length/size FILTER BED ❑ Distance to arest: Well Foundation Property Line SEEPAGE PITS I I ;D' /ance Size Number SUMPS Ll 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, statelaws, 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 dfiusAall for all required ins pe Complete drawing on reverse side. Signed X Title: ( �" Date: FOR DEPARTMENT USE ONLY r Zpricati,nccepted by Date Area Pitrou Inspection by Ma Date Final/a 7 Final Inspection by Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ 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 INFO AMODUNT DUE AMOUNT REMITTED CASH 7 RECEIVED BY �' DATE PERMIT NO. ♦.EH 13-24IREV.1/85) / - /t11� / zo EH 14-26 Y l [[[ �J