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iL - APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE.,,STOCKTON, CA PA"gym EN T Telephone (209) 466-6781 P1 ERMIT EXPiRE5'1 'YEAR FROM"DATE ISSUED (Complete:in Triplicate) `�U� Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install tfte��verlh " ' w made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Ruler3 aZ1d�Ftej "MI T plrcati qu n Local Health District. gid /[,�1 �i" 51 Joaquin r rif .. ,.•� I �J� ��CES 3 Job Addres�6500 Chri s-m-an"Road City Tracy Lot Size PM , Owner's Name "Defense I)e of Trac Address 26500 Chri sman Rd' 220 N. East Street Phon�09-832-9532 Contractor 4�ater QEVe]p�glef7t 6(1;Address W00d1a11d 6A License TYPE OF WELL/PUMP; No. 283-326 Phone 916-662-282 NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ yy� PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER L�r- DISTANCE TO NEAREST: SEPTIC TANK -Ftoo r SEWER LINES' �+- FOUNDATION Na.v. �-- DISPOSAL FLD. PROP. LINE AGRICULTURE WELL '�Sar OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dra. of Well Excavation—.1 'J ❑ Domestic/Private Dia. of Well Casing Gravel Pack 000 Tracy Type of Casing ❑ Public ❑ Other ❑ DeltaSpecifications Depth of Grout Seals Type of Grout El Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. Well Destruction 11 Well Diameter Sealing Material flop 50'I see stattaChe°c(1e Depth Filler Material (Below 50') See a aC e 6 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is Installation will serve: Residence_ Commercialavailable within 200 feet.) Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: SEPTIC TANKWater table depth ❑ T"/Mfg PKG- TREATMENT PLT. ElCapacity No. Compartments Method of Disposal Distance to nearest: Well Foundation" Property Line LEACHING LINE fj No. & Length of lines Total length/size FILTER BED 11 ❑ Distance to nearest: Well Foundation "Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS ❑: Distance to nearest: Well" Foundation DISPOSAL PONDS L3Property Line i 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, an rules and regulations of the San Joaquin Local Health District.. j 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 must call for all required /inspections. Complete drawing on reverse side. Signed 4j.,e" + i Title: Date: PFOR DEP E T US Y Application Accepted bb� 4 Date o�Zr" Are Pit or Grout Inspection Date Final Inspection Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 11 Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE INFO AMOUNT REMITTEDaim 8Y -- DATE PERMIT�NO. + EH 13-24{REV.liH51 .. .� EH 1426 1�i: l 1 _ _ _