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i APPLICATION,FOR PERMIT LI,Y; SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON 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. 1662 for well/pump and the Rules and Regulations of the San Joaquin "Local Health District.'AgDGhGfI S ,--MaG Job Address McArthur Blvd. and Lynne Road -- City Tracy Lot Size 2500'x5500' PM 95851 Owner's Name A. Teicher.t & Son dre 11 Address P.O. Box 15002 Sacramento �honeC916) 386-6982 Contractor L• �• Ads 43 3 License No. Phone_ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTIONS, PUMP INSTALLATION ❑ I SYSTEM REPAIR ❑ OTHER ❑ t DISTANCE TO NEAREST: SEPTICJANK QSEWER LINES __P1h DISPOSAL FLD. 9IN POOP. LINE .12W FOUNDATION AGRICULTURE WELL PJ& OTHER WELL_tLasu_ PITS/SUMPS 10DO1 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom 0 Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications fl Public n Other;. ❑ Delta Depth of_Grout Seal Type of Grout I I Irrigation W_.-Approx. Depth I 1 Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done C Weil Destruction . Well Diameterf_�_ Sealing Material (top 50') Inr. Depth I It}^ Filler Material (Below 501 ` TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is 1 available within 200 feet.l Installation will serve: Residence! Commercial_ Other Number of living units: Number of bedrooms r Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ ,.,4 Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: - Well Foundation Property Line r fi� k SEEPAGE PITS I'1 Depth Size Number tf SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ t 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 taws of California."Contractor's hiring Of sub-contracting signature certifies the following; I certify that in the performance of the work for which this permit is issued, I shall employ. g: ' Y Pe p p y persons subject to workman's compensa- tion laws of California." t 1 I The applicant must call for all required inspections. Complete drawing on reverse side. Signed X_J&42 ! Title: Rr- Date: t X FO_R DEPARTMENT USE ONLY ++pp Application Accepted by Date (J. Area Pit or Grout Inspection by 0 Date aly_,�/i Final Inspection by Date Additional Comments: Y ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca a23-7104 ❑ Tracy 635-63$5 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201FEE INFO rAMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT-NO. r EH 13-24(REV.t/n 5) Vim_ � �s `�.�- ��- _ EH 14-28 v ,