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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT j 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 i PERMIT EXPIRES 1 YEAR FROM DATE ISSUED > e r, F. (Complete in Triplicate) l O !� PD Application is hefeby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. This application is y made in compliance with San Joaquin County Ordinance No.549 for sewage of No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District.- Job Address !C-7771",110-0— /Twp! AP _� � A City J6 AJ Lot Size �TAC � PM "'Owner's Name �`fi}rt>IP_ _—Address s ��i y // y Phone G I� c.� (VIVO+�—. Phonetf"ZContractorJ � `AC040-L -Address yU dlAVLicense ho.L " I TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ s ' F ! PUMP INSTALLATION ❑ SYSTEM REPAIR"O OTHER'""❑ l DISTANCE TO NEAREST: SEPTIC TANK SEWER LINE DISPOSAL FLD. PROP. LINE FOUND!! AGRIC RE WELL OTHER WELL PITS/SUMPS INTENDED USE,, -"^ TYPE OF.'WELL AREA CONSTRUCTION=SPECIFICATIONS 1 �.,�. ❑ Industrial ❑ Open Bottom F anteca.r- `C� -6a of_Well Excavation Dia. of Well Casing ❑ Domestic/PrivateGravel Pack O Tracy Type oflCasing # Specifications j ❑ Public ether .._ `^` --.(,El Delta" ' Depth of Grout Seal Type of Grout r Ll Irrigation �pprox,,Depth ❑ Eastern 11`)J wSurfac. Se 1 Installed by t Repair Work Done ❑ Type of Pump '~'H:P State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50')'""'' Depths Z J 1A 1 Filler Material 18elow 50'1 ( �. TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION DESTRUCTION El (No septic system permitted if public sewer is -------"^4 available within 200 feet.) MInstallation will serve: Residence Commercial_ Othe . ) fir' Number of living unitsi—LNumb rof bedro s +� i Character of soil to a depth of"3�feet: .' ff'�'L-��'^ x Water table depth SEPTIC TANKType/Mfg " T �^C it At rO C 9 R+-I— jiacity 1, No. Compartments PKG. TREATMENT PLT. ❑ .-^"1 r .n Method of Disposal �' l y t! Distance o nearest: Well 0'� Foundation J Property Line U r { LEACHING LINE No.-& Length of lines :3 Total length/size M FILTER BED ❑ . Distance to nearest: * —WellU� Foundation a r Property Line U O t' ' SEEPAGE PITS E] D Depth t SUMPS Distance to'nearest: Well- Foundation ll sr Property Line 3a 4 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 IawS, and rules and regulations of the San Joaquin Local Health District. I 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 folio in "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 Califor a."" Fr The applicant m for all req iredin pec ions. Complete drawing on re rse sid . Signed X Title: —_ Date: ! F R_-DEPARTMENT USE ONLY Application Accepted by 6/ �' '� Date Area Pit or Grout Inspection by Date s Final Inspection by Date � T b Additional Cdir lments: a ❑ Stk 466-6781 € '❑ Lodi 369-3621 'anteca 823-7104 f ❑ Tracy 835-6385 Applicant - Return call copies to: Environmental Il Permit/,Services 1601 E. Hazejton Ave., P.O. Box 2009, Stk., CA 95201 ' tr f t j- a .< -T r FEE AMOUNT DUE' AMOUNT;REMITTED^ CK ¢ RECEIVED BY DATE PERMIT NO. ';INFO .. . CASH / + EH1 !3.20 fREV.1/N51 ' •�/ w } { F ' EH.1428 - . O ter' �? F _ - `19-t I