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APPLICATION FOR PERMIT ^'. SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ` (Complete in Triplicate) w 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 1 made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1 Be for well/pump and the Rules and Regulations of the San Joaquin f Local Health District. j r Job Address `- T 3UFT. f O FtTfSND AI/f. city STDC/IWN Lot Size PM i Owner's Name Address PO. BOX 93D �STDC/�TUti'��J 9S.�DI Phone 9�/•7-/539 r ContractorTi ERA CI�NST�UCTJ"Address 56 y/+/y 470 License No. Phone 8.Z<3 'GV£t/ TYPE OF WELL/PUMP: NEW WELL D9 WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR E] OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL - OTHER WELL PITS/SUMPS INTENDED USE TYPE OFa�WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS El Industrial Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications f ❑ Public ❑ Other ❑ Delta Depth of Grout Seal `d l� Type of Grout ❑ Irrigation_ 4�Approx. Depth ❑ Eastern Surface Seal Installed by f Elf TR < < JR F}/1/1fk I✓ft! State Work Done epair or Done ❑ Type of Pump �_Q�E H.P. Well Destruction �'� ❑ Well Diameter Sealing Material (top 50'! UNERS TDP 97 I Depth Filler Material (Below 50'J ��15E— �3REf�f B077D/'7 30' TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (Noseptic system m emitted if public sewer is {, Installation will serve: Residence L Commercial— Other 1 Number of living units: Number of bedrooms - C Character of soil to a depth of 3 feet: Water table depth f SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal I 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 . I r SEEPAGE PITS ❑ Depth # Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line r DISPOSAL PONDS ❑ 1 C 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 I 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 f 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 i tion laws of California." The applicant must call for all required ins ctions. Complete drawing on reverse side. Signed JDH/!///GY/SE//V� Title: Date: 9.17 FOR DEPARTMENT USE ONLY Application Accepted b Date ! Are ' Pit or Grout Inspection by Date Final Inspection D / 13 ! Additional Comments: /b ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy Applicant- Return all copies to: Environmental Health Permit/Services 1601.E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 f �6 FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT''NO. INFO + EH 13-24(REY.1/85) a ��p �'l�� f EH 1425