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N- APPLICATION FOR PERMIT �V'11 SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELFON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Applica /or install the work descri cation is made inticompliance wiereby thdSano the Joaqu nn Joaquin County Ordinance lNto.District549 for sewage or permit No. 1862 forcwell/dpump and the Rules and IR Regulations of This xhe Sant Joaquin Local Health District. Job Address �y - yf'WAY 7T;t city 751,4V Lot Size 60 AcYer PM Owner's NameBo 7TlY O3'chilare/ Address Phone Contractor 144Vr6±aX1 4 S'v v Address 0#,k BLvt VV olye, License No.ixt-_ r9,/ Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWFR"LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS (` � INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS �\ ❑ Industrial ❑ Open Bottom [r] Manteca teca— Dia. of Well Excavation Dia. of Well Casing C ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications M Public ❑ Other F1 Delta Depth of Grout Seal Type of Grout I I Irrigation _Approx. Depth I I Eastern Surface Seal Installed by - Repair Work Done ❑ Type of Pump H.P. _ State Work Done_ Well Destruction ❑ Well Diameter Sealing Material (top 50'1 Depth Filler Material (Below 501 - TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR I ADDITIONrJ DESTRUCTION I I (No septicsystem permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: fY r Aj&f9 Water table depth B 1 SEPTIC TANK ❑ Type/Mfg Capacity - No. Compartments PKG. TREATMENT PLT.❑ Method of Disposal , 1� Distance to nearest: Well /A 00 Foundation Property Line Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BEDS 6 Ge Distance to nearest: Well 7200 Foundation Property Line Som SEEPAGE PITS II Depth Size �X�X /00 Number 6 SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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." The applicant must call for all required inspections. Complete drawing on rq Title: Date: / Signed % .- R DEPARTMENT USE ONLY 47 Application Accepted by !// /� Date rea Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 8356385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTEDRECEIVED BY DATE PERMIT'NO. INFO a EN 1}24(REV.1/851 ,oO t?\�3 _ EN14A O