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x" APPLICATION FOR PERMIT 401 SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA i, Telephone {2491 466-6781 4 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED yr (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 i; made in compliance with San Doaquin Cbunty Ordinance No-.549 for sewage or No. 1862 for well/pump and the Rules and Regulatiohts of the San Joaquin Local Health District. Job Address 4 r`,�) -- W oOdbiridge Kd,, - City AC11M1201 Lot Size PM ' Bus � �>lyth [Wageln�noffAgN s&ue 33 -A��O. Owner's Name ess Phone ? Contractor, s1<,r+k __ Address__?_0 � 1� License No„? 7 r,Q Phone I TYPE OF WELL/PUMP: NEW WELL 0 WELL.REPLACEMENT RX DESTRUCTION PUMP INSTALLATIONX4_�. SYSTEM REPAIR 0 = OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK tit r SEWER-LINES DISPOSAL FLD.1 df] PROP. LINE Sf1 ` FOUNDATION AGRICULTURE WELL OTHER WELL' PITS/SUMPS _130_ t r INTENDED USE TYPE OF WELL. PROBLEM AREA CONSTRUCTION SPECIFICATIONS .; --- — - r c n , ❑ Industrial ❑ Open Bottom C1 Manteca Dia. of Well Excavatio Dia. of Well Casing i/W._.-__ S] Domestic/Private 30CGravel Pack C] Tracy Type of Casing—,., Specifications #10 FI Public F] Other Fl Delta Depth of Grout Seal 350" Type Of Grouts_$' ..__-_.._-.._.. I I Irrigation _.-Approxi Depth I I Eastern Surface Seal Installed by i Clark Repair Work Done# 0 Type of Pump.. 'SUb H.P.; 2 State;Work Done_ins E,*r1ll f� Well Destruction IR Well Diameter X11 Sealing Material (top 50'I [f� ;. Depth; 1 Filler'Material (Below 50 1 TYPE OF SEPTIC WORK: NEW INSTALLATION 1] REPAIR/ADDITION l 1 DESTRUCTION I I (No septic system permitted if public sewer is ^� A� available within 200 feet.l `\ Installation will serve: Residence_ 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 _ Capacity No. Compartments- PKG. TREATMENT PLT. t.7 Method of Disposal distance do nearest: Well —__ Foundation Property.Line Vr� LEACHING LINE 0 No. & Length of lines Total length/size 1 FILTER BED L) Distancefto nearest: Well Foundation Property Line YE .i ' SEEPAGE PITS I 1 Depth Sire _ Number SUMPS Ll Distance+to nearest: Well Foundation Property Line DISPOSAL PONDS C] Y• j `r I hereby certify that I have prepared this application and that the work will be done in accordance with Sart Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. jt Home owner or licensed agent's signature certifies the fallowing: "I certify that in the performance of the work for which this permit is issued, I shat! 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:suNaw'to-workman's compensa- i tion laws of Calif r i The apptican caq or spe ions. Complete drawing on reverse side. f 1' 7 Signed X ---- Title: V.P C':;.-tom:' Date: -3 C!cr:. 19e y ¢ FOR DEPARTMENT USE ONLY Application Accepted by { a 1 r 1 Arae * � D to ! `J'r Pit or Grout Inspection by . r Date� Final Inspection by Date ' Additional Comments: 3 r, ❑.Stk 466-6781 L I 621. ❑ 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 95201 _4 FEE INFO AMOUNT DUE AM66NT REMITTED CASH RECEIVED BY. DATE RMITNO. �.. 71- 13-21(REV.r/Ksi1�7 EH 11-2a