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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE,TON AVE., STOCKTON, CA Telephone (209) 466-6781 F PERMIT EXPIRES 1 YEAR:FROM DATE ISSUED (Complete in Triplicate} f c.• ; �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 made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rgles and Regulations of the San Joaquin T —Local Health District. ,' �; •...."� ,• _4• . .« 3." _ "a r '('r" C 1LtrS' 4. Z/V2 I fir. L_a r�. : Job Address L Al_ City C OBD 1 Lot-Si,zePM r F6[ Lica 15 Z L G�' - Address Phone f 7 Owner's Name�AL Contractor O rS Address D 1l7 0 License No'77*3 gs Phone 3 ,v qlz' �/ 'rl`f V TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT 13 DESTRUCTION EI a PUMP INSTALLATION 14 -,AX SYSTEM REPAIR IDOTHER ❑ f--A- +� DISTANCE TO NEAREST: SEPTIC TANK —_SCL-- SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS � a f INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS li Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing T } Type of Casing L L Specifications ❑ Domestic)Private �'Graver Pack�^• •❑ Tracy Yp 9 I p Public ❑ Other ❑ Delta Depth of Grout Seal G Type of Grout rox. Depth ❑ Eastern Surface Seal installed by [D Irrigation �.3�APP ' Repair Work Done ❑ Type of Pump COOZ 3S H.P. —71- State Work Done Well Destruction , ❑ Well Diameter Sealing Material {top 501 --,Filler Material iBelow 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ Mo septic system permitted if public sewer is available within-200 feet.) �! Installation will serve: Residence_ Commercial -Other } � 1 # 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'❑� i - - Method of Disposal i rf Distance to nearest: Well Foundation Property Line . LEACHING LINE r ❑ No. & Length of lines Total length/size FILTER SED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS„ [IDepth ` Size Number SUMPS }t �❑ 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 District. 3 "' 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, 1 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 AWA certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ persons subjeato workman's.compens a- tion laws of California." kThe applicant must call for all required inspections. Complete drawing on reverse side. Signed Title: -'.Date; FOR DEPARTMENT USE ONLY Date //UJVti Area '-zI Application Accepted by - 3 Pit or Inspection by Date Li Final Inspection by Dat c - Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy- 835-6385 k Applicant Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED C H RECEIVED 8Y ' M DATE PERMIT`NO., TS10 1 L {. + EH 13-24(REV.i-78 67 - Q 4=5 EH W26