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~4 APPLICATION FOR PERMIT a SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Tripiicatel - Application is hereby made to the San Joaquin Local Health District for a permit kto 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 Ryles and Regulations of the San Joaquin Local Health District. Job Address /7( 90 S• c il I 28d(; _ Ali k 'I City Lot Size _ PM Owner's Name 4 ---- M jCA?S Address '�• Del _ Phone 360 Contractor i [�i+� Address o2oCz,-? M#90;3 License No. Phone bt 0& TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION r AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation r Dia. of Well Casing )<Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout } ❑ Irrigation ---Approx. De�pth1� ❑ Eastern rr Surface Seal Installed by _ Repair Work Done 1 Type of Pump ! H.P. 1• State Work Done .,f Well Destruction 1.1❑ ; Well DiametersSealing Material Uop.50'1 ; S tti2 Depth Filler Material IBei'w 501 S TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION❑ DESTRUCTION ❑ (No septic system permitted if public sewer is 4 { available within 200 feet.l Installation will serve: Residence— Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: f` ' f �'- t' Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments . PKG. TREATMENT PLT. E7j Method of Disposal Distance to nearest: Well Foundation Property Line d LEACHING LINE ❑ No. & Length of lines --�"""" TBtal length%size FILTER BED ❑ Distance to nearest: Well ' Foundation Property Line I SEEPAGE PITS ❑ Depth Size Number s> -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 applicanjMust call for all re dins ctions. Complete drawing o everse side. ,"; i �� TitlDate: � Signed e:' FOR DEPARTMENT USE ONLY ~ µ pA plicati kn Accepted'by `"..` iC t ,` --_ -.Dart (71 Pit or Grout Inspection by Date_ Final Inspectiojtt`li�. Date 010 Additional Comments: t'p�.. `` W ❑ Stk 466 6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 - ❑ Tracy 835 035,1 �,�n `"' ' Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave,, Bo�;2b09, t1c CA 95 .j 0 '..'t� Co FEE AMOUNT DUE AMOUNT REMITTED RECEIV.1. DTE INFO _�— ' EH 3-2r-r,y[y.I/8 51 s 1 k o;-7 ! �S/O ��G7��k ' 'f c•'. - r