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{ APPLICATION FOR PERMIT 40r SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON .AVE., STOCKTON, CA Telephohe (209) 466-6781 - PERMIT EXPIRES 1"YEAR FROM DATE ISSUED (Complete in Triplicate) Application is he+eby 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. Job Address 4 � �� .'.' 5_ City '^0 I Loi Size o f �-�t PM i/., �k.D X90 ?.D°i �' -?(oi Owner's Name Nl r - 'lar: >AQ V� It l�l Address 421 0. �I�'c W Lt2�1�� Phone Contractor {0 Address � 7 r ��j�, LGA.e No. � �U Phon _ 5$� TYPE OF WELL/PUMP: NEW WELL 1'Dieywff�WELL REPLACEMENT ❑ DESTRUCTION C3PUMP INSTALLATION ❑ Z5' ((&p SYSTEM�REPAIR, C3OTHER 0 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES 5 DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Ij ❑ Industrial ❑Open Bottom 0 Manteca Dia. of Well Excavation� /r Dia. of Well Casing ❑ Domestic/Private `�Gravel Pack ❑ Tracy Type of Casing r ye, Specifications ❑ Public F1 Other ❑ Delta Depth of Grout Sea! T �5 Type of Grout .h 1" I I Irrigation VApprox. Depth I I Eastern Surface Seal Installed by _ Repair Work Done 0 ' Type of Pump WA H.P. State Work Done Well Destruction ❑ Well Diameter 2 Sealing Material (top 501 rl M9AwJ*'h �J2lj Depth Filler Material (Below 50') Da wN.9 �o TYPE OF SEUIC WORK: NEW INSTALLATION I'I REPAIR/-ADDITION l I DESTRUCTION') I (No septic system permitted if{ 1 r available within 200 feet.) rj;r;'�� Installation will serve: Residence_ Commercial Other f r?!'t Number of living units; Number of bedrooms VVV S N JOA Character of soil to a depth of 3 feet: Water table dept► QUIN C�}(Jf�A. SEPTIC TANK ❑ Type/Mfg Capacity No. Compart�i ki- r1 PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size 'FILTER BED ❑ Distance to nearest: Well Foundation Property line k SEEPAGE PITS I'I Depth Size— Number SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ f 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 applint st call g—all req fired inspections. Complete drawing on reverse side. Signed X Sr C,0 Title: FO!!4i'eUCo (S f'„ f7. ft 3a� Date: 31 Xy f 9 f _ —�, FOR DEPARTMENT USE ONLY r t Application Accepted by LL Date .9 "Area CpUU Pit or Grout Ins `�'.0'� Final.Inspection by D Inspection by Date ate O / Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 a 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 INFO AMOUNT DUE AMOUNT REMITTED K if CASH RECEIVED BY" DATE ' PERMIT"NO. ♦.EHt3.24(REV.-1/95) �� [2k,t-1 1 r ►� -S-91 ` £H 1t-2e ! 111