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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT M 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-Ml . 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 Regulations of the San Joaquin Local Health District.. . Job Address �i City Lot Size PM Owner's Name loe;;01G AddressT�`�Q /�� Tf� Phone Contractorl;Vi ,uCfi�ir�i�� 1 S Address- 444e.J License No.3719-?-• Phone TYPE OF WELL/PUMP: NEW WELL K WELL REPLACEMENT'E] DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK �� SEWER LINES" DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS j INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION:SPECIFICATIONS It ❑ Industrialpen Bottom C1 Manteca Dia. of Well Excavation Dia. of Well Casing ig Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing- • -f Specifications. _ i ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by I Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing'Material {top 50'i Depth Filler Material(Below 50')1 E OF SEPTIC WORK: NEW INSTALLATION ❑tREPAIRIADDiTION ❑-DESTRUCTION ❑ (No septic system permitted if public sewer is # available within 200 feet./ Installation wi e: .Residence_ Commercial,— Other 9 I Number of living units: Number of bedrooms Character of soil to a depth of 3 j 4 Water table depth I SEPTIC TANK ❑ Type/Mfg �' Capacity No. Compartments PKG. TREATMENT PLT. ❑ � t f Method of Disposal k Distance to nearest: Well Foundation Property Line 4i J LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation rty Line- SEEPAGE ineSEEPAGE PITS ❑ Depth Size,''1' _ Number SUMPS ❑ Distance to nearest: Well`,'_',° Fouhdation Property Line 1 DISPOSAL PONDS ❑ I 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. I 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, 1 shall not employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or-sut-contracting signature certifies the following:"I certify that in the performance of the work for which this permit is issued, I shall employ periohs subject to workman's compensa- tion laws of California." e applicant Il for ill r ired inspections. Complete drawing on gverse side. s Sn Title: Date: FOR DEP TMENT USE ONLY M Application Accepted by Date Area; Pit or Grout Inspection by Date Final Inspection b Date 01 Additional Comments: rL '` D ' ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 8234104 ❑ 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 RECEIVED BY DATE PERMIT'NO. l INFO t } E 1 -2 M 13-24 ©� ✓ ��g�� 3