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k APPLICATION FOR PERMIT i SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA V Telephone (209) 466-6781 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 I S . l� 1 �r City Lot Size PM Owner's Name ! O LEC� �! Address MG V Phone �?70 Yl Contractor To��1 'J� D►✓_-Address go o Z /n RyN License No 7100 Phone 1?1?P4_2&/ TYPE OF WELL/PUMP: NEW WELL•.❑:.., F WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP-INSTALLATION ❑ SYSTEM REPAIR>4 OTHER ❑ DISTANCE TO NEAREST:',SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL } PITS/SUMPS INTENDED USE I�TYP,EiOF WELL PROBLEM'! AREA CONSTRUCTION SPECIFICATIONS 1 ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of VVWE Casing s Domestic/Privafe. ElGravel Pack i CI Tracy Type of Casing ` Specifications ❑`Fubloc�� "- 1 ❑ Other ❑ Delta 1 Depth of Grout Seal Type of Grout ❑ Irrigation i _; ---Approx. Depth ❑-Eastern S rface Seal Installed by c Repair Work Done`�X Type of Pump r.a "� . H.P. �� State Work Done Well Destruction El Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 Gt TYPE OF SEPTIC WORK: NEW INSTALLATION El REPAIR/ADDITION [I DESTRUCTION ❑ (No septic system permitted if public sewer is t a ' 1 :� ,4� � � available within 200 feet.) Installation will serve: \Residence_— Commercial Other Number of living units Number df bedroorris� Character of soil to a depth of 3 feet: Water table depth SEPTIC-TANK'"' —O Type16l 77 Capacity No, Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to°nearest 1 Well Foundation Property Line t LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS LlDepth Size v !~ `Number SUMPS ❑ Distance to nearest: Well �ounda"tion •_ �` `=' Property-Line,'� DISPOSAL PONDS ❑ hereby certify that I have prepared this application and that the work will be done in'acc&1 dance with Sart 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 call f II ire spections. Complete drawing on reverse side. Signed Title: Date: 4-1001 or-1- F611 4 RARTMENT USE ONLY / Application Accepted by "� Date Area Pit or Grout Inspection by Date Final Inspection by7 Date Z L � I Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 D Manteca823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED H RECEIVED BY DATE PERMIT'NO. INFO + EH EH 14-261REV.7/B5l � .71 C:; SI��S9 OCP -