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APPLICATION rOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA 2t� Telephone (209) 466-6781 U PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (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. Job Address 75 Vilest Valpico Rd. City Tracey Lot Size PM Owner's Naml R-PRCi fi n Cnrn.Address K Vgl ni nn Rri Phone Contractor's Name Q1 grin NIRrte 1 Fr Cnrx_icense No. 990448 Phone 4L5-11-3= - TYPE -11 - TYPE OF WELL/PUMP: NEW WELL In WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL __ OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS $ �, }j=1 Industrial /✓ ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private IN Gravel Pack,15XDTracy Type of Casing SJ,� 'Specifications [IPublic ❑ Other $z C3 Delta Depth of Grout Seal 1 >h Type of Grout 13 Irrigation /qf SC�r d("e .Li�G'✓Ci 7�pprox. Depth ❑ Eastern Surface Seal Installed by o Repair Work Done ❑ Type of Pump �� - H.P. State Work Done Well Destruction 11 Well Diameter Sealing Material (top 501r�l yr Ak%A�tr' ,50/ ,.G4/'Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ INo septic system 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: Water table depth - SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments Z w . PKG. TREATMENT PLT. ❑ Method of Disposal rn -0 �Y Distance to nearest: Well Foundation Property Line S 2 U� 1� LEACHING LINE ❑ No. & Length of lines Total length/size_ FIR FILTER BED ❑ Distance to nearest: Well Foundation Property Line X- r (D SEEPAGE PITS ❑ Depth Size Number rn SUMPS ❑ Distance to nearest: Well Foundation Property Line ,) S 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 q�\s`\call for all regquiirre�d inspections. omplate drawing on rave e sly. r-�.\\LeV vo� Y�.(l.-.�0_ Title: Date: 4'-20-85 Signed X�.—, _ 1 M\ FOR DEPARTMENT USE ONLY H-a,�- 96 '117Application Accepted by \ Date /. Area Pit or Grout Inspection by s� - �S Date �� j Final Inspection �bj�yJc� /Date Additional Comments: �� /fLdh2. �il Gj /�r -" h Ile IAW ❑ Stk 466-6781 ❑ Lodi 369-362 ❑ Manteca 823-7104 'D TraI 835-6385 d - Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2DO9, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. INFO 43° o �l-ss gs-yys a EH 13-24(REV.10M 3�S e EH 1426