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APPLICATION FOR PERMIT M F SAN JOAQUIN LOCAL HEALTH DISTRICT s 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 y PERMIT EXPIRES T YEAR FROM DATE ISSUED R (Complete in Triplicate) i 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 Ic Size PM Owner's Name Address hone Contractor �/�J9iU5 ��, AddressLicense No.S//�Rl� Phone_ .TYPE OF WELL/PUMP: t NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ } PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST:' SEPTIC TANK SEWER LINES. DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL. OTHER WELL_ PITS/SUMPS Q INTENDED USE r TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial j4'❑ Open Bottom ElManteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private j ❑ Gravel Pack ❑ Tracy Type of Casing Specifications' t� ll Public } ❑ Other ❑ Delta _ Depth of Grout Seal Type of Grout--- I rout _I I Irrigation $ !'� _ _Approx. Depth l I Eastern --Surface Seal Installed by _ Repair Work Done C7 Type of Pump . ��.� H.P. J 7 Z- State Work Done�N 'Jy�L� 5N291>jA Well Destruction i ❑& Well Diameter Sea0q/g aterial (top 50'1 �!�_r�.1�/�� K/�.LL �/c�J�L L Depthr Filler Material {Below 501i _ i TYPE OF SEPTIC WORK: NEW INSTALLATION f l REPAIR/ADDITION 1.1 DESTRUCTION I I (No septic system permitted if public sewer is F i available within 200 feet.) , Installation will serve:,- Residence� C-ommerciai_—Other Number of living units: Number of bedrooms Character of soil to a-depth of 3 feet: Water table depth `~ -SEPTIC TANK t '❑ Type/Mfg, CapacitNo"Compartments PKG. TREATMENT PLT # � Method of Disposal ' . Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ Noe &Length of fines-'�-} 1-' Total length/size FILTER BED € ❑ Distance to nearest: —Well `s _ Foundation Property Line -� -SEEPAGE PITS f 11 Depth Size_ Number SUMPS L71 Distance to nearest: Well' [ Foundation Property.Line _ Y DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that Che 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 peFformance 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 compansa-- tion laws of California." E The applicant r I requ" ctions. Complete drawing on vers side. Signed X01 Title: e%d � G!i Date: N _ u FORD ARTMENT USE ONLY Application Accepted by s. A,,^l Date Area Pit or Grout Inspection by ® � Date r� G'Fiinal Inspection by Data U Additional Comments: �/�/ ( ,O.ti4!JXl 7�/W- ❑ 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 INFO OUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. ! +.EH13-241REVx .3/ 5] _�c47 97- 3/21' r EH 14-26 �� f 3s