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`7 APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 7 YEAR FROM DATE ISSUED f k�- , (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 I 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 Districty� a x 1� C °tri1 Job Address I^LA L PM City Lot Size ff Owner's Name ' Q CR—_ Address S +� % d Phone !7rl— 40(400 Contractor's Name �L i t L S License No. 6 � � f 3 � '� � Phone b 6 TYPE OF WELL/PUMP: NEW WELL ❑" WELL REPLACEMENT ❑ DESTRUCTION Cl PUMP INSTALLATION ❑- SYSTEM REPAIR P--' OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL-FLD. PROP. LINE x FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS L ❑ Industrial E:1 Open Bottom El Manteca _ Dia.-of Well,Excavation Dia. of Well Casing L�YDamestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing`^ Specifications , ❑ Public ❑ Other ❑ Delta Depth'of Grout Seal t Type of Grout' ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by74 Id 3e�.ee Repair Work Done Ro Type of Pump a�� _ - State Work Done Well Destruction ❑ Well Diameter Sealing Matarial�{top 50') r Depth Filler Material (Below,50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted it public sewer is available within 200 feet.) .� Installation will serve: Residence_ Commercial_ Other N Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg _Capacity No. Compartments PKG. TREATMENT PLT. ❑ 4 Method of Disposal 'Distance to nearest: Well Foundation Property Line I LEACHING LINE ❑ No. & Length of lines Total length/size ; FILTER BED ❑ Distance to nearest: Well Foundation Property Line r I 1 SEEPAGE PITS ❑ Depth Size Number t SUMPS ❑ Distance to nearest: :Well' Foundation Property Line DISPOSAL PONDS ❑ e 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 District. Home owner or license signature certifies the following: "1 certify that in the performance of the work for which this permit is issued, I shall not employ any person' such mann r as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature certifies the follo ing:"1 certify t at in-the performance of the work fgpqliich this permit is issued., I shall employ persons subject to workman's compensa- tion laws of C ifornia." { The applica must li fa wired ins ction Ing o reverse � 0 Signed it e. eDate: J /� FOR DEPARTMENT USE ONLY `.., Application Accepted b AAAAQ Date Area , Pit or Grout Inspection b Date Final Inspection by Data Additional Comments: /w ❑ Stk 466-6781 ❑ Lodi 369 1 ❑ Manteca 823 104 Q Tracy 5-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009,•Stk., CA 95201 t FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT"N0. INFO CASH �r +fH13-24/REV.10/$31 LA S. .o 1 � 3`.�S.S9 EH 14-28