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APPLICATION FOR PERMIT .�� SAN ,lOAQUIN LOCM. FicAI,TH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (2091 466.6781 MAY 16 1995 ; ; PERMIT EXPIRES 1 YEAR FROM DATE ISSUED lComplete in Tripljc3te) Application s hereby made to the San JoaCurn Local Health District for a permit to construct and/or install the work herein described. This applicalinn made in compli,rnce with San Joarlum Cottnry Ordinance No. 549 for sewage or No. 1862 for well/pump and the Rules and Regutalions of the San Joaqu� Local health District. Job Address .15 ICA S T lQ HRA,cL city . TRAC-r Lot Sire PM Owner's Name I" Owl Address 3 �CJ We S 0� S� Phone(: D2,� 1 2 Contractor•_. Address �� :_ ' T - • License No. i. Phone &6 �Jf >T-i► ' TYPE OF WELL;PUMP: NEW WELL ❑ WELL REPLACEMENT DESTRUCTION u PUMP INSTALLATION : SYSTEM REPAIR 0 OTHER X Yo. 't 9 3 DISTANCE TO NEAREST: SEPTIC-TANK SEWER LINES DISPOSAL FLO. PROP LINF _ _ v FOUNDATION AGRICULTURE WELL OTHER WELL 3C ` PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Li Industrial CJ Open Bottom G Manteca Dia. of Well EtrcavatFon Dia. i I-Van ' r Domestic/Private n Gravel Pack )5 Tracy Type of Casing Specifications P,,bl,c I '. Other '- Delta Depth of Grout Seal Type of Grout t,n,ldlion Approx. Depth Eastern Surface Seal Instilled by ' Repair Work Done Type of Pump H P State Work Done ' , ,[�fXr- GEMENT 'Nell Destruction Well Diameter Sealing Material Itop 50'1 Depth A-o ft a Fidler Material l8elow 501 ^� TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRIADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence r.._ Commercial— Other Number of living units: Number of bedrooms ' Character of sod to a depth of 3 feet: Water table depth _ SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal ' Distance to nearest: Well Foundation Property Line LEACHING LINE 0 No. & Length of lines Total length/sire --- FILTER BED G Distance to neatest: Well Foundation Property Line SEEPAGE PITS I I Depth Sire Number SUMPS Ll Distance to nearest: Well Foundation Property Line ' DISPOSAL PONDS L7 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, in, 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 lot which this permit is issued. I shall no ' employ any person in such manner as to betaine subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signatur, certifies the following: -11 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 c or all requ• inspections. Complete drawing on reverse side. ' Signed X Title: y Cy�0��_S_ Date: 3 -L g- 9 S- -) FOR DEPARTMENT USE ONLY / Application Accepted by Dare `„0 ` Area Pit or Grout Inspection by r� Data Final Inspection by Date Additional Comments: t�� - e'y1G V-0CIL(- l.yl�l�f-•, &A%d 6(Ad kv riCp ,- ❑ Sik 466-6781 ❑ Lodi 364.3621 O Manteca 823.7101 ❑ Tracy 835.6385bf Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, SM., CA 95201 I� INFO AMOUNT DUE AMOUFfT AEMITT>D t`Asa� RECEIVED BY DATE PERM67'N0, EE 41 EFF 13I4 TREY- n Si qJ) J�j4i&; C