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I APPLICATION FOR PERMIT h SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA D V u Telephone (209) 466-6781 �I li PERMIT EXPIRES 1 YEAR FROM DATE ISSUE OCT 01g8g I! (Complete in Triplicate) ii Application is heieby made to the San Joaquin Local Health District for a permit to construct and/or install tEk'VdR(k(*VtEN AT tkapplication is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for wall/pump and the RIERMlT�i�sa 4 San Joaquin Local Health District. r Job Address 27539 S!i ,LAMMERS RD. CityTRAf'V_,„,v„_ Lot Size PM ii. Owner's Name PAUL 01-SHOS Address 31 EAST 6TH. ST.....__,__.._.., TRACY, CA Phone 832- . u ContractorNFNNiNCC RRfITTjLL�Address3ra2aT�LA"„�Pr nt-,rT�— License No. 290813 Phone545-1185 TYPE — TYPE OF WELL/PUMP: NEW WELL IN WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST:-.SEPTIC TANK - .1 00 'A -SEWER LIN ESr 1-0.0 1 + DISPOSAL FCD. PROP. LINE p FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE fPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation 12" Dis of Well Casing 'r �I Domestic/Private )P(Gravel Pack (Tracy Type of Casing PVCC h 1 60 cifications F] Public F Other CI Delta Depth of Grout Seal t '� Type of Grout RFNTONTTF F I I Irrigation _Approx. Depth 11 Eastern Surface Seal Installed by n D T)_) IhIC C 0— Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50') I TYPE OF SEPTIC WORK: NEW INSTALLATION I REPAIR/ADDITION I I DESTRUCTION l I (No septic system permitted if public sewer is I !; , available within 200 feet.) I Installation will serve: Residence_ Commercial— Other I i 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 LEACHING LINE ❑ :No. & Length of lines Total length/size FILTER BED El !,;Distance to nearest: Well Foundation Property Line i. L -4—i—SUMPS SEEPAGE PITS I I depth Size Number ❑ 4Distance to nearest: Well= r- -Foundation Property Line' Jand DISPOSAL PONDSCl �!f hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state la 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 k employ any person in such manner as to become subject to workman's compensation laws of California.” Contractors 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." Ij The applicant must call for all',required inspections. Complete dr wi1R1everse side. Signed X i)SU_14n � Date: 10 FOR DEPARTMENT USE ONLY �J Application Accepted b Ii n 1 G pp P y Date rea Pit or Grout Inspection by I Date Final Inspection by e �I Additional Comments: �� «Z " /q Q ❑ Stk 466-6781 ❑ Lodi 36V621 ❑ Manteca, 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'N0. +.EH 1321(REV.1/8 5) l �r 16/ ` EH 11-28