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APPLICATION FOR PERMIT SAN JOAQUIN-LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA 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 k made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pum Local Health District: p and the Rules and Regulations of the San Joaquin { ;t Job Address 24 O 7:7 )- +[ !?/�f_�'�'1 l'�,. Cityc5("C,COY, Lot Size - PM Owner's Name Address )lone Contractor dS Address S:ZJ ense No. CX613 Phone TYPE OF WELL/PUMP: NEW ELL-XL WELL REPLACEMENT El DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ 3 DISTANCE TO NEAREST: SEPTIC TANK Z2/ 1 �._ SEWER LINES DISPOSAL FLD.-L3�4'PROP. LINE FOUNDATION _ AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation I] Dia. of Well Casing omestic/Private (Grave! Pack 17 Tracy Type of Casing. —I e _ specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal — /+ 10 ❑ Irrigation _meq Type of Grout pprox. Depth ❑ Eastern Surface Seal Installed by /'-» Repair Work Done ❑ Type of PumpH.P. State Work Done r Well Destruction ❑ Well Diameter Sealing Material (top 5D') Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ {No septic system permitted if public sewer is Installation will serve: Residence_ Commercial— Other available within 200 feet.) Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth i� SEPTIC TANK EI Type/Mfg Capacity No. Compartments _ 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 + SEEPAGE PITS ElDepth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line - DISPOSAL-PONDS ❑ o, 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, an 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."Contractors hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work for which this permit is issued,!shall em tion laws of C lifornia." pto Y pijrsonssubject to workman's compensa- The applica must call for ail r it d inspection Complete drawin ev rse de. ' Signed Title: Date: a o� R DEP MENT USE ONLY Application Accepted by kAll . F DateP J Area Pit or Grout Inspection by Date Final Inspection by,� i. Date C Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369- 1 ❑ Manteca 823-7104 ❑ Tracy 835-8385 ;� alo 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 cK INFO RECEIVED BY EDATEJPERMIT'NO. EH 13.24{REV.l/951 c), 76- �©l+ ri l^ � � �--2)-2 SS EN 14-28 ( {LVti k