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, APPLICATION FOR. PERMIT ~. . SAN JOAQUINaLOCAL HEALTH DISTRICT ' 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 4664794- 4/ PERMIT EXPIRES 1 YEAR FROM DATE ISSUED r (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. AC Job AddressF!J �� ",/GrJs- City�` rN Lot Size �� / PM _ Owner's Name ' C10 9X/ CL�iVL Address IRAC Phone -6 -L—03 Contractor l' T+ CAO 9-S Address License No. 7S Phone TYPE OF WELL/PUMP: NEW WELL �WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP'INSTALLATION ' f SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE n FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS �dl INTENDED USE F TYPE OF WELL PROBLEM AREA' CONSTRUCTION SPECIFICATIO ❑ Industrial -1� 15-0 peh Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing %Domestic/Private Gravel Pack ❑ Tracy Type of Casing 7—i-e-4 I Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal TO LJ Type of Grout ❑ Irrigation 0�+pprox. Depth El Eastern Surfagee�eal installed by r�L✓ /{� � Repair Work Done LJType of Pump �U H.P. S* ttttFFFI/� State Work Done r Well Destruction ❑ Well Diameter Sealing Material (top 50') _ Depth Filler Material fBelow 50'I - T TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet► Installation will serve: Residence= Commercial— Other t I Number of living units: Number of bedroomsE 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 I LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth r Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS El 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 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 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 call for all re fired inspections. Complete drawing on reverse side. . .+? Signed X Title: 1}-1 � Date: — FOR DEPARTMENT USE ONLY Application Accepted by Date 6: Area 4)6 ��y/C.� 1 Pit or Grout Inspection by Date` - Final Inspection by 4P/lrDate i Additional Comments: ❑ Stk 466-6781 ,❑ Lodi 369-3621 ❑ Manteca -7704 ❑ Tracy 835-6385 +L Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED INFO - CA RECEIVED BY DATE PERMIT N0. + EH 1 -24(REV.s i H 57 �o y r�, EH 144-26