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APPLICATION FOR PERMIT s' f SAN JOAQUIN LOCAL HEALTH DISTRIC q�lrl 1601 E. HAZELTON ON AVE., STOCKTON, C Telephone (209) 466-6781 Kii.�'�+ - PERMIT EXPIRES 1 YEAR FROM DATE SSUEb l ��,I � �� !,-� yV( (Complete in Triplicate) �p g Application is hereby made to the San Joaquin Local Health District for a permit to constr t and/or inst 1 the worrk h�rein�de�scrib 6e- app)cation is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 or well/pump and the Rules and Regulations of the San Joaquin Local Health District. n t i f Job Address 3125 E. Orange Street j City- Aca?rlpo tot Size 10 L 000 § ftPM ) Owner's Name San Joac!uin County Address 1810 E. Hazelton Avenue Public Works Department Phone 944-22811 Contracto Address P• ' License No.A_O8�2�Phone 33 d77 42 TYPE OF WELL/PUMP: NEW WELL EDWELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION CR SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES NZA DISPOSAL FLD. PROP, LINE -Z5—' FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation 1 ❑ Domestic/Private r Dia. of Well Casing 201 f� Gravel Pack ❑ Tracy Type of CasingSteel Specifications Attached i I brig li 550,her Cl Delta Depth of Grout Seal 200 r ILLIh1. Cement Grout I I Irri dtion Type of Grout g ' —__Approx. Depth I 1 Eastern Surface Seal Installed by Contractor , Repair Work Done ❑ -Type of Pump SubmersibleH P 50 State Work Dane_ Well Destruction ❑ Well Diameter Sealing Material Itop 50'1 Depth ., Filter Material (Below 50'I 1 TYPE OF SEPTIC WORK: NEW INSTALLATION- 11 REPAIR/ADDITION i I DESTRUCTION i I (No septic system permitted if public sewer is I Installatio ! serve: Residence— Commercial! Other available within 200 feet) Number of living unl Number of bedrooms Chloracter of soil to a depth of 3 SEPTIC TANK ❑ 'TWater table depth Type/Mfg Capacity No. Compartments PKG.' REATMENT PLT. ❑ i Method of Disposal Distance to nrearest: Well Foundation Property Line } F7 } LEACHING LINE ❑ No. & Length of lines I Total length/size FILTER 8 E ❑ Distance to.Aearest: Well Foundation Property Line SEEPAGE PITS I 1 Depth I Size SUMPS Number T.l l� Distance to nearest: Well Foundation Property Line DISPOSAL PONDS C) d 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." f The applicant must all for ail required ins tions. Complete drawing on reverse side. l Signed x IENRY TRATA —. Title: Director of Public Works Date: 7-11`7 `� = O EPUSE ONLY Application Accepted by Date gip Area Pit or Grout Inspection by E z _ - DateY;tmal Inspection by Data Additional Comments: x ❑ Stk 466-6781 D Lodi 369-3621 Cl 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 FEE INFO AMOUNT DUE AMOUNT REMITTED CK CASH RECEIVED BY DATE PERMIT"NO. + EH 13-21(REV.1/K s) • 5Y 7S! 14-2aEH -2e