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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 (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 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. � q ,7a� ' Jab Address __. _ �_ � Ciwa2y~ Lot Size PM Owner's Name l _ Address � � Phone Contractor_ Address s7w License No. i TYPE OF WELL/PUMP:• NEW WELL ❑ 1 'WELL REPLACEMENT ,l] DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM FIEPAIR ❑ OTHER ❑ Q 'i DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE, . # FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS- s ' INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom.pp;; ❑ Manteca Dia. of Well Excavation Dia. of Well Casing E) Domestic/Private ❑ Gravel Pack+ 0 g' D Tracy Type of Casing Specifications r ❑"Public ❑ Other d ❑Delta Depth of Grout Seal Type of Grout ❑ Irrigation ---Approx. Depth ❑ Eastern"' IN Surface Seal Installed by E ``Repair Work Done ❑ Type'of Pump " ! H.P. ` State Work Done ° Well Destruction ❑ Well Diameter Sealing Material (top 501 I j Depth Filler Material i Blow. '} TYPE OF SEPTIC WORK: -NEW INSTALLATION ❑ REPAIR/ADDITION IV DESTRUCTION ❑ iNo septic system permitted if public-sewer is available within 200 feet.} F _ Installation will serve:r'''Residencett— Commercial__ Others .+ _V; +"Number of living units:l 02 — Number of bedrooms rlk Character of soil to a depth of 3.feet: �""`` — "" :Agr""W'ater table depth SEPTIC TANK ❑ Type/Mfg. Capacity �• y, No. Compartments l PKG. TREATMENT PLT. F1i - Method of Disposal ; a Distance to nearest:-; - Wella 4,,, foundation Property Line LEACHING LINE No. & Length of lines Total length/size Airly FILTER BED ci k f istance�to nearest' Wellf.,�/f Foundation/ [? ^/`Propert; Line i SEEPAGE PITS Depth Size f� rr�ber SUMPS ❑ Distance to nearest: ell Foundation Property Line �� f DISPOSAL PONDS [D i , I hereby certify tha4 I have prepared this}application and'that the work will be done in accordance with San Joaquin county ordinances, tate laws, and rules and re gulations'of,the�Sari Joaquin Local Health District- Home owner or licensed agAtIs`signature certifies the following: "I certify that in the performance of the workforwhich this permit is issued, I shah noty employ any person in such manner as to become subject to workman's compensation taws of California."COntractoes hiring or sub-contractinblsignature certifies the following: I cern that in the performance of the work for which this anti is issued,I shall employ persons subject to workmin's cam nia � „ certify Pe Pe P Y Pe 1 Pe tion laws of California."r r I F s The ap st call for a ad inspe tions Complete drawing on reverse side. 4Signed Title: Date' . f. ti,A FOR DEPARTMENT USE ONLY , A,pplicati pled by Date � —�f) Area * A r rS ......... y ,�"•7-'f•`-T- •y ,rxe+n:�rw.r. .--,.,. �.r e er: ou;`Inspection by Date_ Final Inspection by b. .Y s 'r �srl•aYi..r'- - r Ad oiial Comments: i : Y 5p 17h ❑ Lodi 369-3621 - -❑ Manteca 823-7104 0 Tracy 835-6385 ptica 21all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 ' e FEE INFO AMOUNT DUE AMOUNT REMITTED GASH - RECEIVED BY DATE PERMIT`NO. + EH 1324 TREY.1,1a 5Y ^`' EH 14-28 / VVV