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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 i 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. . ai E 9AZT 40 AC Job Address � a �� City Lot Size PM Owner's Name f c2J- CAI! -S -AAddress �JO ` X75 LT Phone "5 T3 Contractor ��lSWt ��(J� .I Address/I-F 5iM-Ai0&I�p��dLicense No_ 6 Phone 5-- '40 r TYPE OF WELL/PUMP: I NEW WELL W WELL REPLACEMENT ❑ DESTRUCTION ❑ # ^ PUMP INSTALLATION SYSTEM REPAIR ElOTHER L1DISTANCE TO NEAREST: SEPTIC TANK [/....:__. SEWER-L-INES---/D-Q-----DISPOSAL FLO.j 5f PROP. LINE 1 FOUNDATION IVRV AGRICULTURE WELL rTvk2— OTHER WELL PITS/SUMPS INTENDED USE: TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial �-0pen Bottom ❑ Manteca Dia. of Well Excavation Y Dia. of Well Casing yi ! A'Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal p Type of Grout -A-4-AT CiTM ❑ Irrigation Approx. Depth ❑ Eastern Surface Seal Installed by ' Repair Work Done ❑ Pum �'Type,�of v Pump.�» H.P. State Work Done Well Destruction ❑ Well Diameter 1 E I Sealing Material (tap 501 i Depth - Filler Material (Below 501 I 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 Number of living units: Number of bedrooms -- +-,: Character of soil to a depth of 3 feet: �s..e. Water table deptH S, SEPTIC TANK ❑ Type/Mfg CapacityNo. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal e j Distance to nearest: Well Foundation Property Line l� Q if LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth ° Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line v. ' DISPOSAL PONDS ❑ It 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. u 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 n6t 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 cdmpensa- tion laws of California." I: The applicaFtust Iar all squired i pections. Complete drawing on reverse s'ide.�'� Signed Title: �0 W r r� Few- Date: FOR DEPARTMENT USE ONLY ` . Application Accepted by Date 1� Area f Pit or ro t Inspection by "" Date 11)--4 Final Inspection by T-520 - Date = -�= Additional Comments: 4 ❑ Stk 466-6781 ❑ Lodi; 369-3621t ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies tok Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOU` INFO 7� NT DUE AMOUNT AWITTED'i 9H 1 RECEIVE -D BY t DATE PERMIT NO. -+ (REV. /a 5) �� �t/ ,f'. EH 1425 1 S'�