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APPLICATION FOR PERMIT ' SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 P ° ^' 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 Sari Joaquin County Ordinance No. 549 for sewage or No. 1862 for wellipump and the Rules and Regulations of the San Joaquin Local Health District. r Job Address e r T City Lot Size PM Mt. D iCX160 O N& Owner's Name �e� Vy�1�lvrs,1 Address qu Phone ``}} Contractor A i Terr-Ql 11 `_AddressF2t7�P.1/�11:p, i f1,A qEU3 a License No. Phone q TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR LJ OTHER e PieZQtl Det" t DISTANCE TO NEAREST: SEPTIC TANK 7S�{C�.._... SEWER LINES TSQO' DISPOSAL FLD.A(Q_ PROP. LINE FOUNDATION �._,_..__ AGRICULTURE WELL _fir OTHER WELL PITS/SUMPSOO INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing 2 �� ❑ Domestic/Private FrGravel Pack ❑ Tracy Type of Casing p Specifications �jetti�ci>11 4 1-1 Public ❑ Other XDelta Depth of Grout Seal A7 Type of Grout I I Irrigation 5WApprox. Depth I 1 Eastern Surface Seal Installed by _ Repair Work Done 0 Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 r I Wager lP,Vels Depth Filler Material (Below 50'] TYPE OF SEPTIC WORK: NEW INSTALLATION l 1 REPAIR/ADDITION I I DESTRUCTION i I (No septic system permitted if public sewer is m available within 200 feet.I I Installation will serve: Residence_ Commercial_ Other 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 j r PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line _� f LEACHING LINE Ll No. & Length of lines Total length/size 4 I FILTER BED ❑ Distance to nearest: Well Foundation Property Line t SEEPAGE PITS I I 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 Di?;trict. 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 lawsofCalifornia."Contractor's(tiring or sub-contracting signature I certifies the following: "I certify that in the performance of the work for which thisFpe mit is issued,I shall employ persons subject to,workman's compensa- tion laws of C iforni r The applic t ust call for requ� din ns. Complete q4jng A. reverses`+ Q F / (70 Si ned ills: Q Date: U O 1 E:;R1 FO DEPARTMENT USE ONLY ,,ll Application Accepted by Date l/ Area O= Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: LI Stk 466-6781 ❑ Lodi 369-3621 0 Manteca 823-7104 fl Tracy 635-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 iFEEO AMOUNT DUE AMOUNT REMITTED C H A RECEIVED BY DATE PERMIT'NO. r EH 14-26 J �"'\ 1 � 4 i 51