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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1641 E. HAZEL T ON AVE., STOCKTON, CA Telephone (249) 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. 1861 for well/pump and the Rules and Regulations of the San Joaquin Local Health District.j Job Address d1 O x�. TO + City Z All t=/� Lot Size PM Owner's Name &S S,: i(,ddress 103302A T k/ F" CA Phane "'74 �0�1 1?�� \r�i4T0R �yST dres 0 !/,eb d� Y6 8 8/ License No. Phone 0 TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK I D fSEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavatio Dla. of Well Casing Domestic/Private �Q Gravel Pack ❑ Tracy "Type of Casing S� ifications Ce,.,_�`e�r ❑ Public ❑ Other ❑ Delta Depth of Grout Seal �� ~7� T pe of Grout ❑ Irrigation ---Approx. dept ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump od H.P. 5 State Wok Done ��, �.TA.0�C +�� Al vV Well Destruction ❑ Well Diameter Sealing Material (top 501 r Depth Filler Material (Below 50') PA-L/6— TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION M 'DESTRUCTION ❑ (No septic system permitted if public sewer is ,A'.; , I available within 200 feet.) Installation will serve: Residence_ Commercial— Other " Nurnber of living units: Number of bedrooms 0% Character of soil to a depth of 3'feet: '"` ,"Fr "' Water table depth f SEPTIC TANK ❑ Type/Mfg P Capacity No. Compartments PKG. TREATMENTS PLT. ❑ C _ 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 SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Pro arty'Line p DISPOSAL PONDS ❑ ,r 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. I 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."' 4> The applica ust cal or I required inspections. Complete drawing on rev rsea side. Signed Title: v Co Al rf?A CTo Date: FOR DEPART ENT USE ONLY Application Accepted y 7A,1 f 7Ar Date J! ` ' Area Pit or Grout Inspection r Date�� Final Inspection by � � Date�� f/ ::r* n`,j VJ-�� r°(�Fv -rklck"- _J f .tom Additional Comments. b -cr t J �� t��{ �� 'tol�6rdl A[.c -h> y�ect- ftiys.� d Y ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 la Tracy 835385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 952bl FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT''NO. INFO CASH + EH 1 EH 11-128 /92'7 24iREV.s/957 —6a'R