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..� APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZETON AVE., STOCKTON, CA Telephone (209) 466-6781 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. Job Address /166-1 '?A1 uv1 ROA C', City A1APQTL--C A Lot Size PM Owner's Na - Address QJD- dDy_ aC)ZZ mijx:l co Phone J Contractor ' yU' Addres � �✓!A � � License No zSSS& � hone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER fA 4 DISTANCE TO NEAREST: SEPTIC TANK 125 SEWER LINES A)/,Q DISPOSAL FLD.d2A— PROP. LINE 106 FOUNDATION `-SD AGRICULTURE WELL OTHER WELL _,L r PITS/SUMPS ,S2,14 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom El-Manteca Dia. of Well Excavation 'K�r Dia. of Well Casing Vbomestic rivate 10�rtravel Pack ❑ Tracy Type of Casing fvC- Specifications F1 Public Ll Other ❑ Delta Depth of Grout Seal 1.2O" Type of Grout 419ff-12-AWW 2 \ I I Irrigation Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter 2frPVC Sealing Material (top 50') A_)Q9T Ck_-7nc;ix_)f &PcxiT Depth 2.S-C3 ? 941.' Filler Material (Below 501 N---AT t0 TYPE OF SEPTIC WORK: NEW INSTALLATION ( I REPAIR/ADDITION I I DESTRUCTION I I (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: Water table depth �. SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line J LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS ❑ Distance to nearest: Well 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 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 Calif The applicant ust all for all r ire pact- Complete drawing on re arse side.LZ y� Signed X Title: � 9r/111 Date: FOR DEPP#RTMENT USE ONLY /, ^� !' / Application Accepted by Date 16 ca� V Area Pito Grou Inspection by Date 64JFinal Inspection by Date Additional Comments: ❑ 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 AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT'NO. INFO . EH/3-24(REV.i i 9 5)