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F. APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT I 1601 E. HAZELTON AVE., STOCKTON, CA ( Telephone (209) 466-6781 t PERMIT EXPIRES 1 YEAR FROM DATE ISSUED t (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:- ' - t] sb Job Address R �� Lcity _SX7C Lot Size 3�t7 AGr?E PM Owner's Name 'yN7"1l oF__5� AfAk4Address �� z/�Z 7-&Y 19,16 Phone z� �6�'J4�a�O t i Contractor s + g1Lf:L0P14 5y7_Address ZG� 1144.Srs7 '*LM A License No. 283326 Phone -?- TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATI.ON ❑. T y - SYSTEM REPAIR ❑ OTHER IJ' h;6d1 �'�� DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL'FLD.'—_. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL Qr�e� J PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS q ❑ Industrial ❑ 00 an Bottom C] Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private t caravel Pack ❑ Tracy Type of Casing_15 8o ��G Specifications k ('l Public ❑ Other F1 Delta Depth of Grout Seal /3© Type of.Grout 04GLs4 i I I Irrigation - "--Approx. Depth { 1 Eastern Surface Seal Installed byk_)iFi'15X_ Repair Work Done ❑ Type of Pump H.P. State Work Done _ r Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I'] REPAIR/ADDITION i I DESTRUCTION i I ANo septic system permitted if public sewer is 1 available within 200 feet.) Installation will serve: Residence_ Commercial_ Other Number of living units: Numberofbedrooms Character of soil to a depth of 3 feet: Water table depth r SEPTIC TANK ❑ Type/Mfg I Capacity ' No. Compartments a PKG. TREATMENT PLT. ❑ Method of Disposal 1 Distance to nearest: Well Foundation Property Line `I LEACHING LINE' C1 'No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line. SEEPAGE PITS, • i I Depth Size _ Number SUMPS Cl Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I " " I 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. 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." I The applicant ust call f all re fired inspections. Complete drawing on reverse side. Signed X Title: Date: FOR OEPARTNIENT USE ONLY Application Accepted by Date Area Pit r Grout nspection by Date Final Inspection by Date i Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ll ❑ Manteca 820104 bkracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95241 f r FEE INFO AMOUNT DUE AMOUNT REMITTED CA5H RECEIVED BY DATE PERMIT'NO, I{ +'EH 13-24 tnev.I/Ar) 3S. 00 137.{ 10--ir-gy _ EH 14-2a