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y r 1 �j 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 Jin County Ordinance No.549 for sewage or No. 1862 for well/pump and.the Rules and Regulations of the San Joaquin Local Health District. pAY/ { Job Address -_/ —1 �40 City �— 7— Lot Size J � Id`® PM Owner's Name f J T �Z4S T C/VAVdress hone' Contractor's Name -License No. �`4-_a S�° ?hone i -T- YPE OF WELL/PUMP:.- - -- • - NEW-WELL e- WELL REPLACEMENT ❑ DESTRUCTION ❑ ' PUMP INSTALLATION "�` SY.STM`REPAIR ❑ OTHER 0v DISTANCE TO NEAREST: SEPTIC TANK �L�/V�SEWER LINES i - DISPOSAL-FL^D. ' ='=PROP. LINE I FOUNDATION AGRICULTU_RE WELL OTHER WELL-- _ PITS/SUMPS INTENDED USE t .TYPE OF WELL PROBL M AREA . CONSTRUCTION SPECIFICATIONStF_d Q Industrial a. 0'Opan--Bottom L•Manteca -,,,-Dia:'bf Wall-Excavation 74 Dia. of Well Casing t ❑ Domestic Privet XiGravel Pack ❑ Tracy Type of Casing 15 AG, Specifications S ,❑� Publ' ❑-Other ❑ Delta Depth of Grout Seal ' � Type of Grout S�` frrigatIon-.,__ � � !�tA_pprox. Depth � ❑ Eastern Surfa a Se I Iflstalled by i Repair Work Done"\❑ Type of Pump T�U� H.P. ` State Work Done k� f Well Destruction ❑ Well Diameter Sealing Material (top 50') 14 Depth Filler Material (Below 50'1 4 TYPE OF SEPTIC_WORK: NEW INSTALLATION ❑ REPAIR/ADDITION El DESTRUCTION Ll (No septic system permitted if public sewer is (� ...�, - -"— "'I, k available within 200 feet.) dy E Installation will serve: Residence_ Commercial_ Other E Number of living units: 7 Number of bedrooms II' 'Character-of soil to a depth of 3 feet: Water table depth - " SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments I }' PKG. TREATMENT PLT. O Method of Disposal Distance t2 nearest: Well Foundation Property Line LEACHING"LINE s ❑ No. & Length of lines Total length/size r1 1 FILTER-BED O Distance to nearest: Well Foundation Property Line a SEEPAGE PITS ❑ Depth Size Number y [ f SUMPS- �, El Distance to nearest: Well Foundation Property Line I c ti DISPOSAL PONDS O I herebyrc"ertify that I have°prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and r 3 = 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 must call for all required inspections. Comp) awing-on reverse side. Signed X � -- � � Title: Date: i t "FOR DEPARTMENT USE ONLY Application Accepted by A Date Area <_Pit-or_Grout•.Inspection-by� - -- - -- ate--- - -Final-Inspe t6 ion-by --- --- - _Date s & Additional Comments: a) r lj11ti5 X 9 ro ce-P S ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823VIN4 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201FEE CK Ic INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. f + EH 74-241REV.101831 EH14-28