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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA I f>�d �N `0 Telephaine (209) 466-6781 p PERMIT EXPIRES '1_YEAR.FROM DATE ISSUED 14i f. Sw dr . ,.f (Complete in Triplicate) j. 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 c Local Health District... a�a 7 .ss7a , �. �• � 133 , Job Address City ti Lot SiPM / �7�rTE,D--I R Owner's Name Address 220,1 , X&_4 ,pa— Phone / 6 r Contractor's Name License No. OLU Phone c?V7-o391V TYPE OF WELL/PUMP: NEW WELL JSP WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION » SYSTEM REPAIR ❑ em OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES lco `f DISPOS4' FLD PROP. LINE FOUNDATIONAGRICULTURE WELL Alave, OTHER 1NELL Q'[1 $M APS• /U0 Ur INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 1 _ ❑ Industrial - ❑ Open'Bottom Ll Manteca Dia. of Well Excavation V Dia. of Well Casing Domestic/Private JAI Gravel Pack ❑ Tracy Type of'Casing LTr6_d Specifications y ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout 4)TOIJ 17 ❑ Irrigation ----Approx. Depth ❑ Eastern Surface Seal installed by Repair Work Done ❑ Type of Pump S(� H.P. .3 State Work Done Well Destruction ❑ Well Diameter Sealing Material {top 50'1 _ Depth Filler Material (Below 501 1 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION.❑ INo-septic system permitted if public sewer is -: -ava"ble-within 200-feet:l'— .. 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 0, Type/Mfg Capacity No. Compartments I PKG. TREATMENT PLT. I Method of Disposal .Distancetolnearest: Well Foundation {t Property Line s LEACHING LINE ❑ No. Length of lines Total length/size .'. FILTER BED ❑ Distance to nearest: Well Foundation_ PropertLine ~ # SEEPAGE PITS ❑ Depth 0. Si z Number SUMPS " El Distance to nearest:. Well Foundation 2"" Property Line DISPOSAL PONDS ❑ hereby certify that I have prepared this application and that the work will be ne in accordance with San Joaquin county ordinances;state laws, and rules and regulations of the San Joaquin Local Health bistrict.` Home owner or licensed agent's signature certifies the following:Vl 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*orkman'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." i The applican st call for all r aired in pections. Complete drawing on,reverse side. Signed Title: > Date: FOR DEP RTMENT USE ONLY ; - Application Accepted by Date Area Pit or Grout Inspection by �� Date �� Final Inspection by Data A itionaI Comments: —` L106k _ tk 466 6781 ❑ Lodi 36&3fi21 Manteca 823-71 ❑ Tracy 835.6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED % K RECEIVED BY DATE PERMIT"NO. +EH 13-24 EH 13-26(REV.10183) � i