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I 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' (C&nplete in Triplicate) i,,. - fy�.�yLl Application is hereby made to the San Joaquin Local Health District fora 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 Reles and Regulations of the San Joaquin -Local Health District. - - t�71L;, '°ti r t�• "^►• fs' - -� ' Jf- (_ti5 �� / fC° �% s . �1 F" Ci ``� tLot Size I'M Job Address ��`�G2G4 ' 1�, f _ Owner's Name ` W i u.ct Address __ !zJ � 7 � ' Phone 727 _ 7GY Ll 7 �`�10 �� 6;7Contract r TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPL_A_CEMENT ❑ DESTRUCTION ❑ r - T - --- PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ T OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK EWER LINES ✓t4T DISPOSAL FLD. PROP. LINE #? FOUNDATION AGRICULTURE WELL_ OTHER_WELL _PJT-5!_SU.MPS_�_. I INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation t Dia. of Well Casing ; ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other Q Delta Depth of Grout Seal Type of Grout ❑ Irrigation __4pproz. Depth ❑ Eastern Surface Seal Installed by ! n Repair Work Done ❑ Type of Pump H.P. t State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') .� Depth Filler Material {Below 50'1 TYPE OF SEPTIC WORK: NEW INSTALLATION Q' REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is i V available within 200 feet.l Installation will serve: Residence Commercial_ Other Q f I Number of living units: Number of bedroo �l f Character of soil to a depth of 3 feet: .G ��-►� --7o P � Water table depth o� SEPTIC TANK ❑ Type/Mfg r t _ e5i 't.�4Capacity X l No. Compartments PKG. TREATMENT PLT. ❑ r 1 r'U Method of Disposal Distance rto nearest: Well �� Foundation m n, Property"Line LEACHING LINE GeYNo. & Length of lines ' i p X . g � Total length/size � I FILTER BED ❑ Distance'to nearest: Well 100 Foundation /0 `l Property Line 4 1 SEEPAGE PITS (Zf Depth Number SUMPS ❑ Distance!to nearest: Well Foundation -- Property Line ___ DISPOSAL-PONDS p— I hereby certify that I have prepared this application and that th6 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 tfia 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 khat in the performance-of the work for which this permit is issued,1 shall employ persons subjecr.to workman's;compensa- tion laws of California:" The applicant t st call for all�j\squired inspections. Complete_drawing on reverse side. Si ned - eq �� g � �C.r TitEe: .'.,'�� ,,�` r FOR D ARTMENT USE ONLY ; Application Accepted by v �� Area t or Grout Inspection by Date rg Fina1 Ispection by' 41 4 i- Additional Comments: C f i ❑ Stk 466-6781 ❑ Lodi 369-362 '�E]'Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to:.Environmental Heallti-Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUEL; AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. �. - '+ EH14-2tilREV.t/ssl