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4 _ y APPLICATION FOR PERMIT _ � SAN JOAQUIN LOCAL HEALTH DISTRICT _ � 1601 E. HAZELTON ON AVE., STOCKTON, CA + Telephone (209) 486-6781 PERMIT EXPIRES 1'YEAR FROM DATE ISSUED � ?,� E%; s, (Complete in Triplicate) 11� ri-P ,rYs Application is herebymade to the San Joaquin Local Health District for a permit to construct and/or install the work herein descF6ed..T;h�s� pplication is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for wellipump and the Rules arrfdiQ'Jpia ii<?fdami the San Joaquin Local Health District. 2�� KA .SSOILI rZoAD Ci 'BdAIT/ Lot Size (2 t crk--s PM 0410 C_ i4WO IZAHOA/ Job Address Q' Owner's NameCsA Address _$AAJ aAMOAL !94_9l4-5e'3 Phone` j � q52 6 1 � 1Z5 K`t kTL� Sig'• -7 Contractor 5License No. 512 2-68 Phone ZQ'9 l�iAf3�# TYPE OF WELL/PUMP: tsytz(al��V WELLS WELL REPLACEMENT ❑ DESTRUCTION ❑' / PUMP INS L(ATION ❑ r SYSTEM REPAIR LJTH.ER DISTANCE TO NEAREST: SEPTIC TANK/10 WIFE'.SEWER LINES 2rb WO' DISPOSAL FLO "- "OP OP. LINE�� r ,FOUNDATION7F5 © AGRI"COUTURE WELL ~� OTHER WELD�WPITS/SUMPS ° '� i INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation 11,4 • Dia. of Well Casing L4 f f ❑ Domestic/Private ❑ Gravel Pack V Tracy Type of Casing PV c, Specifications n Public -' ❑ Other f F1 Delta Depth of Grout Seal S t Type of Grout�z i Ifri t o '30_Approx. Depth I I Eastern Surface Seal Installed by - %kiAIC. epair Work Done ❑ Type of Pump H.P: State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 50') a TYPE OF SEPTIC WORK: NEW INSTALLATION l 1 REPAIRYADDITION 1.1 DESTRUCTION l I (No septic system permitted if public sewer is j available within 200 feet.) OI Installation will serve: Residence 4 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 0 Distance to nearest: Well Foundation Property Line 1 4 LEACHING LINE ❑ No. & Length of lines Total length/size F FILTER BED ❑ Distance to nearest: Well Foundation Property Line I SEEPAGE PITS 1 1 Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line G 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. 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 10 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 mu c�i II req d inspections. Complete drawing on reverse side. f p r igned X Title: `�� . - 4�z r Date: J — l 6 fL7l a FOR DEPARTMENT USE ONLY 9 Application Accepted by " Date + A Pit or Grout Inspection by Date Final Inspection by / Date ® i Additional Comments: ❑ Silk 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 y FEE AMOUNT DUE AMOUNT REMITTED CK H INFO RECEIVED by ' DATE PERMIT'ND. 06 + EH 13-24(REV. i n 51 3S rj "� A106 1 Ilk f 1 7wl,06. EH 14-28