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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT N0. $3- Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM GATE ISSUED DATE ISSUED (Complete in Trip]icate} 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/ and the Rules and Regulations of the San Joaquin oval Health District. pump Job Address bdivision Name Owner's NameAddressk Contractor's Name License No, �__- Phone LIU i Phone TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT DESTRUCTION PUMP INSTALLATION SYSTEM REPAIR OTHER ❑ ; 4 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISP05AL FLO. PROP. LINE 0 FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS ,rn� INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECTFICATIONS IJ Industrial 0 _ f 4 LJ pen Bottom Manteca LDia. of Well Excavation U Domestic/Private ~ Gravel Pack Tracy � !Dia. of Well Casing i Public G Other ❑ Delta �:/ V Irrigation Type of Casing Approx. Eastern Cathodic Protection Depth C pecifications Geophysical e wP De th of Grout Seal # ' , �- LJ Other 'T,�pe of Grout ' Surface Seal Installed by 'Repair'Work Done �} Type of Pump H.P. i State Work,Done ell Destruction Well Diameter Sealing Material ial (top 50 ) ` A f Depth.. FiT1er Material (Below 50' /TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION U (No septic tank or seepage pit permi,fted-if public sewer is Installation will serve: Residence ';cOther `a`ailable'within 200 feet.) Commercial t ' Number of living units: _� Number of bedrooms , Lot ize Eek Character of soil t6.a depth of 3 feet: R F Water table depth SEPTIC TANK ,� � I Type/Mfg y y �Capacitya, Compartments i a i �1PKG1 TREATMENT PLT.. Type/Mfg ! GFapacify F °" Method of Disposal SEWAGE.SYSTEM s ac ~ DESTRUCTION Distance to nearest: Well ++ � Foundation = Property',Ljrte 'LEACHING LINE No. & Length of lines Total length/sized" FILTER.BEDN J0 Distance to nearest: WellFoundation f-�— Property Line /® + SEEPAGE PITS Depth Size Number €' , er' i SUMPS .T�U aDistance to nearest: Well JBL Foundationd, Property Lin DISPOSALtPL''i 0N05 ,.F e . I I hereby certify that I have prepared this:appl�icatio~n 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—TF6`'ollowing:-`"I"certify-`that-in'th'e performance of-the -for-which--this permit is issu , I Shall not employ any person in "s6ch'manner as to become subject to workman; compensation laws of Californib." Contractor's in or sub-contracting ature certifies the following: "I certify that in the performance"of the work for which this permit issued, I shall employ pers ns subject to'workman's compensation laws of California." -/ The appli t 11 for requi inspections. Complet dra 'n o reverse•s.ide. .� Signed X' Title: �� 1 'A *`x °� i ' ' +I Date: Y FO f =RTMFUSE. NLY' Application Accepted by ' Area Stk 466-5781 # J" Additional Comments: Lodi 364-3621 Pit or Grout Inspection by t_a �,='Da•tey s/0 Manteca 823-7104 � } Final Inspection by Da e+ / -.• Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 t FEE BASE AMOUNT DUE AMOUNT REMITT.EiT �eRELIV V'' YkrNFO °�YDATE vy PERMIT N0. EN 13-24 RE U. 10/821.0/52:500— 14-26