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. 1 Y APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEILTON AVE., STOCKTON, CA Telephone (209) 466-6781 !v+ 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 Regulation of the San Joaquin Local Health District. Z ��j �'A_�� City c Lot Size 7 PM Job Address — Q-t,,f�S MAJ j(� hone Owner's Name Address l � _ �13r- 3zro p Contractor S Address icense No. Phone °7 `�� TYPE OF WELLIPUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ , PUMP iNSTALLATION4 SYSTEM REPAIR C1 OTHER L] 7 / DISTANCE TO NEAREST: SEPTIC TANK . SEWER LINES DISPOSAL FLD._/jg -PROP. LINE !�� CO J/,E-FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS rte" INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Q ❑ Industrial Q Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing �Oomestic/Private Gravel Pack '� Tracy TYPa o �ng - SPeccations; C1 Public + ❑ Otlyer ,❑ Delta. - _. Depth of.Grout Se t Type of Grout';` ❑ Irrigation AQApprox. Depth' '❑ Eastern Surface Seal Installed by , Repair Work Done F1 Type of Pump H.P. /� State Work Done r Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material {Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION (a REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is c available within 200 feet.) Installation will serve: Residence— Commercial_ Other !1 + Number of living units: Number of bedrooms Capacity No. Compart Character of soil to a depth of 3 feet: Water table:depth, n ' mennts - i SEPTIC TANK ❑ Type/Mfg PKG. TREATMENT PLT. 71f i I Method of Disposal i Distance to nearest: Well/ Foundation Property Line LEACHING LINE ❑ No. & Length of dines 4/ Total length/side I FILTER BED ❑ Distance to nearest: I Weld + Foundation Property Line SEEPAGE PITS .i1 Li- Depth j Size s Num be, " SUMPS t T ❑ Distance to nearest:' Well Fodndation Property Line .1 DISPOSAL PONDS ❑ I hereby certify that 1 have prepared this application and that the work will be donein-accordance witfi S nrJoaquin counWIMdind'nces, state t is, and rules and regulations of the San Joaquin Local Health District. -�* Home owner or licensed agent's signature certrfies,the following: "I certify that in(the'performance of the work for which this permit is issued, l shall not employ any person in such manner as to become subject to workman's compensation Jaws 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 erinpi6y persons subject to workman's compensa- tion laws of California." The applicant f all:nppecti6ns-1. Complete drawing on a side. I r 1 Signed Tiile Qate: r } FOR DEPARTMENT USE ONLYALI + i } �'* Application Accepted by _ Date Area r -7 Pit or Grout Inspection b k^�- Final Inspection by. _ Dat�✓, _ ," t ' Additional Comments: -' ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104-- ❑Tracy. 835-63% Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 N. FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT`N0. INFO CASH + EH 13-241REY. /ss) EH 1446