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IM E_ 'i APPLICATION FOR PERMIT 9 SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, GA 1j Telephone (209)'466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in,Triplicate) , �L 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 ��7�/=1 - Lot Size PM Owner's Name y Addreis p Phone Contractor ,Z, UL L,--Ad(fress ( Dt �y/. License Ivo, Phone TYPE OF WELL/PUMP:' 1�NEW WELL El WELL REPLACEMENT 7 DESTRUCTION ❑ I "PUMP INSTALLATION ❑. :.� ,SYSTEM REPAIR ❑' OTHER ❑ i DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS � y ❑ Industrial L1 Open Bottom El Manteca Dia. of Well Excavation Dia. of Well Casing I t b ❑ Domestic/P4vate ❑ GravellPack ❑ Tracy Type of Casing Specifications x ❑ Publics r -Ti Oiher� `' """' ❑-Delta— Depth of Grout Seal Type of'Grout i ❑ Irrigation r __Approx. Depth ❑ Eastern Surface Seal Installed by j Repair Work Done Q- Type'of Pump H.P, State Work Done_ t Well Destruction C s Well Diameter Sealing Material (top 50') t Depth Filler Material (Below 501 g N T E OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is M �- -- -max - -^-y-� - availaiile witliin.200 feet.] Installation will serve: Residence1_ Commercial�Other Number of living units: V Number bf bedrooms U Character of soil to a depth of 3 feet: +97V //I--_ Water table depth SEPTIC TANK Type/Mfg Capacity--! No. Compartments �:Z 1 PKG. TREATMENT PLT. ❑ a sp I ss Method of Disposal t Distance to nearest: Well J&111'' Foundation`. ' s k Property Line_�G "r� i: LEACHING LINE ❑ No. &Length of lines Xy- Total length/size FILTER BED Distance to nearest: Well Foundation 0F9` I Y` s 1 Property Line 1 � < ... E SEEPAGE PITS ❑ depth Size Number : SUMPS€ ❑,.,. Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ i r f I hereby certify that I have prepared Uiis application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and rul&s and regulations of the San Joaquin Local Health District. ! s Hofne 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 it he performance of the work for which this permit is issued,'I shall employ persons subject to workman's compensa- tion laws of California." -� f The applicant`-must-call-for- 11 require dinspections-Complete.drawing on reverse sida`- -"""""'f �` ` s F Signed Title:lk jDate: &:Ft FORDEPARTMENT USE ONLY Application_Accepted by e 11066 k Date Area — I Pit-or Grout I s ction by— d __i. ° 4 rt rye _ _ Date Final Inspection-by -iVie � Date Adtlitiiinal Comments: . i �1 - .;,--I , -- L;v ;!!\ �, I i ❑ Stk;466-6781 '❑ Lodi 369-3fi21 anteca 82i 71 QA 1'❑ Traeyr%-835x6385 e Applicant- Return all copies to. Envi onmental Health Permit/Services 1 1 E. Hazelton Ave, P.O.-Box 2009, St 95201 € y FTFO '— AMOUNT!DUEt_. ..,•.AMOUNT-REM1 TEDD. CK -- RECEIVED BY -.�- 'INtDATE-�- PERMIT'NO+ EH 13-244REV.1/H 51 -ft.1 4EH1428 . Qtr