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-- APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6791 i 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 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 District. Job Address 30,/ W. M I4_6 .,City TQ_C_-=l1 Lot Size PM Owner's Name Y OnINE PS 11� 1 Ad 1 9 W. H-w. 1. I Lp�j [A PhoneC r+r�. � Contractor "Address 2$ 4 .5 'NY Rite 51se No.61224o Pi1on!Licen �L0 71-2 i TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER E--WON ITOI?,#tj6 DISTANCE TO NEAREST: SEPTIC TANK 3$ SEWER LINES DISPOSAL FLD, PROP. LINE eQ-?op i FOUNDATION 1!9 t AGRICULTURE WELL OTHER WELLI'.3n PITS/SUMPS _ t I INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation g Dia. of Well Casing vt ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing PVC- FI Specifications rµ$t0 VJ (1 Public (Other—F4f)�/1TJ1�II�Qj�Delta Depth of Grout Seal LdlJKAJoW Type of Grout f I Irrigationt ��"" 12D-Approx. Depth ( I Eastern Surface Seal Installed by %1AFWRyJ01e_sO m I�G Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50.1 TYPE OF SEPTIC WORK: NEW INSTALLATION l 1 REPAIWADDITION I. ) DESTRUCTION I ) 1No septic system permitted if public sewer is Installation will serve: Residence_ Commercial_ Other available within 200 feet.l Number of living units: Number of bedrooms � Character of soil to a depth of 3 feet: SEPTIC TANK LJ Water table depth Type/Mfg Capacity Water PKG. TREATMENT PLT, ❑ Method of Disposal 1 Distance to nearest: Well Foundation Property Line N"( LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation ` Property Line �qN SEEPAGE PITS 11 Depth Size _ Number ; SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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 licensed agent's signature certifies the 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 that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa tion laws of California." The applicant Rust call al require inspections. Complete drawing on reverse side. Signed X � ` Title: J'- Date: FOR DEPARTMENT USE ONLY Application Accepted by Date Area d` Pit or Grout inspection by Date Final Inspection by Date Additional Comments: + ❑ 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 AMOUNT DUE AMOUNT REMITTED INFO CASH RECEIVED DATE PERMITNO. � 50 �.EH 13-24 tREV.t/951 ? �/ ��-0606 EN 13-28 f.