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I APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT PAYmENT t 1601 E. HAZEL T ON AVE., STOCKTON, CA RECEIVED Telephohe (209) 466-6781 51` P PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 8 198 (Complete in Triplicate) ENVIRONMENTAL HFALTH Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work hegiRAtkAT .' ' cation is made in compliance with San Joequiri County Ordinance No. 549 for sewage-or No. 1862 for well/pump and the Rules and Regula long o t e an Joaquin Local HealthDistrict. Job Address 26202 AGNOT.TA City ESCAL01i Lot Size PM Owner's Name TERRY. GULMAN Address 2220 NISSION ST. Phone gag_7130 CONTRACTCRS # Contractors lar--Pn pUmg3ts i C_Address License No. Phone529-2,020. TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑C SYSTEM REPAIR ❑ OTHER ❑ ` DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS : - 1NTENDEO-6 S�ETYPE-OF WELL u PROBLEM0EA�'CONSTRUCTION_SPECIFICATIONS` ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing X1 Domestic/Private ❑ Gravel Pack >❑ Tracy Type of Casing Specifications 1"1 Public Cl Other ❑ Delta Depth of Grout Seal Type of Grout I trrigation --Approx. Depth { I Eastern Surface Seal Installed by _ Repair Work Done ❑ Type of Pump S1 JB H.P. 1 SState Work Done 31M.- SI;iU Well Destruction ❑ Well Diameter Sealing Material (top 501 f Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR IADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is r(� available within 2D0 feet.) installation will serve: Residence_ Commercial_ Other Number of living units: . Number of bedrooms Character of soil to a depth of 3 feet: 't Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ 1 Method of Disposal t 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 SEEPAGE PITS l 1 Depth Size Number SUMPS Ll Distance to nearest: Well Foundation Property Line ---�DISPOSALPONDS-...;:--❑ 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 Di%trict. 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." The applicant call for all equire actions. Complete drawing on reve a side. Signed Title: Date: or FOR DEPARTMENT USE ONLY �� Application Accepted by d Date Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: ❑ Stk 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 85201 FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT'NO. INFO CASH V +.EH 1324(REv.5/h 57 3 5 3S 1�(�/J Q— Z Of iy�ZZ y0 ' EH 14-28 1(J f I i