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�3 APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON 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 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 City _ 7rbt�6ize PM << qQ e Owner's Nam�l &JU;:40$` Lu, ^ Phone -.T � 5 , Contractor l iMti Address A2 C:)c 19 ?,l License No./62- 5 73 Phone V6 42, dS TYPE OF WELL/PUMP: NEW WELL CRY' WELL REPLACEMENT 9?* DESTRUCTION PUMP INSTALLATION Weo' SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing D6omestic/Private Uetravel Pack ❑ Tracy Type of Casing &V Specifications M Public ❑ Other Cl Delta Depth of Grout SealType f Grout.. V I I Irrigation z2WApprox. Depth I I Eastern Surface �$ aal Installed by Repair Work Done ❑ Type of Pump Ste- I H.P. �L' State Work Done_ Well Destruction P**"Well Diameter Sealing Material (top 501 y\� Depth Filter Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 R(PAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is y� available within 200 feet.) VV 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 PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size _ _ Number SUMPS Ll 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 o e nt'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 arson in such nner as to become ct to workman's compe tion laws of California."Contractor's hiring or sub-contracting signature certifies t following: "I cert: Shat in an of the wo is is ermit is issued I shall employ,persons subject to workman's compensa tion law of Califor ia." The ap licant al r requi ti omplet drawing n e i e.1 Signed '' 9 -� Title ' Date: FOR DEPARTMENT USE ONLY f Application Accepted by ". Date L �C),C—i Area_ 3O Pit or Grout Inspection y Date Final Inspection by l // Date Additional Comments: rc au L- we'r d.-,Ut' W tT* Lrto ❑ 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 INFO A///MOUNT DUE AMOUNT REMITTED CK X/-CASH RECEIVED BY DATE PERMIT•NO. +.EH13.24(REV.I/A5) �!//, C /- y EH 14-26 N '� Gv