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y APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED i (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. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Joh Address c2&q& '1 ZG(1 f {f „ City Lot Size PM "a Owner's'Name 4 A G P_ B12 l. 6)1 Address P P n n_' Phone ' q ? Contractor •iJ � �!� Address �- 7. Q V- g /License Na. 4 ��J Phone a TYPE OF WELL/PUMP: N WELL EI WELL REPLACEMENT ❑ DESTRUCTION ❑ 1 PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLDJ-550_ PROP. LINE 40 , FOU�ND�ATlON ��► AGRICULTURE WELL OTHER WELL PITS/SUMPS ? INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta ..Depth of Grout Seal Type of Grout ❑ irrigation ---Approxv Depth r...❑ Eastern Surface Seal Installed by , Repair Work Done 171 Type of Pump S,,ki H.P. {-- State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 t Depth - b Filler-Material.(Below SW TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ 'REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is ' available within 200 feet.) 10 Installation will serve: Residence fi Commercial_ Others 6 Number of living units 7�' ,�N'T rr be o bed ooms # s Character of soiltoa d epth of 3 feet: Water table depth SEPTIC TANK 'r� ❑ Type/Mfg Capacity No. Compartments I PKG. TREATMENT PLT.r❑ Method of Disposal f -Distance to nearest: Well Foundation Property Line G LEACHING LINE ❑ No. & Length of lines Total length/size—..A FILTER-BED .... E]� Distance-to-nearest:. Well —Foundation- �—_-- Property:Line— i { f SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line 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. 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." E 4 1 The applicant must VII for all required inspections. Complete drawing on reverse side. Signed X_ o AJ. 19'Y-- Title:_�s e- r S . Date: F f F DEPARTMENT USE ONLY I Application Accepted Date /.2 2_p-96 Area 7 Pit or,I1_ y Grout Inspection by Pate Final Inspection b f t,>/ Data 3' { - Additional Comments: /V ❑ Stk 466-6781 _ElLodi 369-3621 ❑ Manteca..823-7104 El Tracy 835-6385 Applicant- Return all copies to: Environmental HealtK-Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNTt)U AMOUNT REMITTED CK CASH RECEIVED BY DATE PERMIT NO. EH 1$24(REV.1/8 51 .. ` EH 14-25 7�. �� / bb"�57