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APPLICATION FOR PERMIT 1C� SAN JOAQUIN LOCAL HEALTH DISTRICT i j� 1601 E. HAZELTON AVE., STOCKTON, CA � Telephone {209} 466-67$1 PERMIT EXPIRES 1'YEAR FROM DATE ISSUE (Complete in Triplicate? p n{� Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the woD &T—i&escl"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 t the San Joaquin Local Health District. ENVIRONMENTAL PIEALT14 PERMIT/SERVICES Job Address City Lot Size PM Owner's NameAddress 3 321 -)<-E Phone Contractor da;_./ .-.�-.-�i1L I r`_Address 100 /Q,/ f� /�di��~ - S se fVo. elf Phone?12 � TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. POOP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS R INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS El Industrial - 0 Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing dDomestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications n Public f! Other C-1 Deita Depth of Grout Seal Type of Grout i I Irrigation Approx. Depth I 1 Eastern Surface Seal Installed by _ Repair Work Done 0 Type of Pump f9"14-- H.P-161 n _ State Work Done gd IF Well Destruction ❑' .-*Well Diameter Sealing Material (top 56 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION 1 1 REPAIR/ADDITION I I DESTRUCTION 1 1 (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence— Commercial Other `k. Number of living units: Number of bedrooms d 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: Well Foundation Property line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ( I Depth Size Number SUMPS L1 Distance to nearest: Weil ` 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 Di§trict. 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 x employ any person in such manner as to become subject to workman's compensation taws 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 cal i all required'in4 mctions. Complete drawing on AZO-4— side. Signed X Title: AZO-4— Date:zd"h FOR DEPARTMENT USE ONLY / Application Accepted by Date QA 40 0 Area v Pit or Grout Inspection by ate Final Inspection by /[sTn Date Additional Comments: Ll 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 AMOUNT DUE AMOUNT REMITTED CASH CK I RECEIVED BY DATE PERMIT'NO. + EH 1}Z41REV.ti/H5f EH 11-26