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T i APPLICATION FOR PERMIT SAN JOAQUIN LOCAL_ HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR.FROM DATE ISSUED (Complete in Triplicate) y 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 Rules and Regulations of the San Joaquin Local Health District. I Job Address AICL76 _446— city Lot Size PM w Owner's Name ' 8 4 Address Q A'I' �[J� Z / Phone _ Contractor's Name CL-.—(C SvAA License No. 6 S 7;t, ?hone 3 3� I TYPE OF WELL/PUMP: NEW WELL LJWELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES _ DISPOSAL FLD. _ PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS , y INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca pia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications Q Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by p{} Repair Work Done LJ Type of Pump H.P. State Work Done Well Destruction IDWell Diameter Sealing Material (top 50') Depth Filler Material (Below 501i TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is availa*within 200 feet.) Installation will serve: Residence e/ 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 - r_1W Cl"dfCapacity�/.Zsy No. Compartments f PKG. TREATMENT PLT. ❑ + ' Method of Disposal I Distance to nearest: Well �d Foundations Property Lime LEACHING LINE E?"-No. & Len th of lines o6' p 9 Total length/size FILTER BED 121 —Distan6 to nearest: Well Foundation,- Property Line± SEEPAGE PITS Er Depth izei"_-� Number Z—, SUMPS ❑ Distance to nearest:' Well .� ° d l = Foundation _ Property Line DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work will be"done in accprdance 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;ompensation laws of•Califorriia."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." x 4 ,, i The applicant must call al required%inspections. Complete drawing or�e verse side:} + ' ,] Date: p Signed N � t �� Title. � � � a .�JAY • FOR DEPARTMENT USE ONLY Application Accepted by ' Date 7f iL/ Area_ 1!5�21 Pit r Grout Inspection by L Date 4 Final'Inspection by Date Additional Comments: i z ❑ Stk 466-6781 O Lodi 369621 ❑ Manteca 823-7104 C7 Tracy830385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUEAMOUNT REMITTED CK* RECEIVED BY DATE PERMIT"N0. INFO CASH r +£H 1324/REV.101ffi1 /yam. r EH 14-28 S o / 3�Iz