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` l APPLICATION FOR PERMIT t 1 SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone 1209) 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 madain 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. Joh Address ✓ U City f Lot Size PM Owner's Name CIC, V.. Address Contractor Address C-0 rax - ✓.�_ License No. �``�-� Phone 20 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT EJ \-:'i DESTRUCTION ❑ '_P`UMP IN5TA"TION ❑-- "" SYSTEM -REPAIR ❑' OTHER - ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP, LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE ❑ Industrial ❑ Domestic/ Private I'1 Public I i Irrigation Repair Work Done ❑ Well Destruction ❑ TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Open Bottom -. _13- Manteca—_ T ,Dia. of -Well -Excavation ❑ Gravel Pack ❑ Tracy Type of Casing Cl Other Cl Delta Depth of Grout Seal -Approx. Depth I I Eastern Surface Seal Installed by s � Type of Pump H. P.' State Work Done _ Well Diameter Sealing Material atop 50') Depth r — -Filler •Material.�Below 50').. -. — - Dia. of Well Casing _ Specifications Type of Grout _ I YVE ut- SEPTIC WORK: - NEW INSTALLATION 1, ?REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is II //available within 200 feet.} Installation- will serve: Residence V _ Commercial Other Number of living units:Number of bedrooms Character of soil to a depth of 3 feet: t ''n Water table depth - SEPTIC TANK aType/Mfg G n Capacity [C�:�." No. Compartments PKG. TREATMENT PLT, ❑ Method of Disposal - ^--T• �--- --w Distance to nearest: Well;_._ -Foundation_._?= Property.Line 4 LEACHING LINE 9� No. & Length of linesT Total length/size FILTER BED ❑ Distance to nearest: Well 100 Foundation Property Line �- C SEEPAGE PITS i I Depth Size SUMPS 0 Distance to nearest: Well DISPOSAL PONDS ❑ Foundation Number Property Line nereny cerury tnat I nave 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 Di>;trict. 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, f 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, 1 shall employ persons subject to workman's compensa- tion laws of California." The applicant must call for all required 'ns ctions. Complete drawing on reverse side. Signed X Title: A 6, -�_ Date: IG of OR DEPARTMENT USE ONLY Application Accepted by Date y Area _ Pit or Grout Inspection by Date Final inspection by Date Additional Comments: LJ Stk atiti-timi LJ 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 AMOUNT DUE AMOUNT. REMITTED CK RECEIVED BY INFO CASH DATE PERMIT'NO. +. EH 13.24 PIEV, I i x 51 � EH 14-2e