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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES TYEAR FROM DATE ISSUED (Complete in Triplicate) Application is her bby 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 DistHct. ! I f I`I- U �QIL �C � t� Lal Size f a 1PM I Job Address _� _ City b Owner's Name 1 t5— Y Address Phone�� 3 7 ' TS C Contractor G t Address nse No 0?`7►'7 Q�� Phone C-313 i TYPE OF WEL PUM : NEW WELL 13 WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION F� SYSTEM REPAIR ❑ OTHER ❑ t DISTANCE TO f AREST: SEPTIC.TANK .SEWER LINES, DISPOSAL FLO, PROP..LINE FOUNDATION AGRICULTURE WELL OTHER WiECL't= PITSISUMPS 7 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom El Manteca Dia. of Well Excavation Dia, of Well Casing IN Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications # I'1 Public ❑ Other Cl Delta Depth of Grout Seal Type of Grout AI Irrigation —.-Approx. Depth I I Eastern Surface Seal Installed by / Repair Work Done ❑ Type of Pump `7u- H.P. ��'- State Work Dan tYl/� �! r I Well Destruction ❑ Well Diameter �_...— Sealing Material (top 50') Depth Filler Material (Below 50') ` -- TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION t I DESTRUCTION { I (No septic system permitted if.public sewer is j available within 200 feed. Installation will serve: Residence_ Commercial_ Other � s r<�'It g rr fel;. .�;. Number of living units: � i Number of bedrooms i �� �- Character of soil to a depth of 3 feet: Water.tirre depth ``..., SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Meth4.� Pisgovl } Distance to nearest: Well Foundation Property-Line r IIL .V11/1N F;,r LEACHING LINE Ll No.No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 1 I. Depth Size Number SUMPS ❑ Distance to nearest.. .Y Well xFaundation_ - P.►operty,Line- r- U 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 Di§trict. 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 must call for I required inspections. Complete drawing on reverse sid(L,loll �} ` Signed X Title: Hate: FOR DEPARTMENT USE ONLY Application Accepted by Data 7--/ Area Pit or Grout Inspection by date Final Inspection by Data Additional Comments: A(O5'�el,,- El j0❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ 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 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT-NO. INFO CASH .EH 13-24 JREV.f/x5) 7f bflb °.H 14.29