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s APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1f 3- 1601 E. HAZEL I ON AVE., STOCKTON, CA Telephone (209) 466-6781 GQp PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ^ 0 (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. , 1 _ Job Address C1171` City `^Mk Lot Size PM Owner's Name 0. Uuwtvi; Address +I is +9 �� 76 Phone Za2' Contractor's Name ` WV icense No. J Phone TYPE OF WELL/PUMP: NEW WELL WELL REVLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK �Ue� SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIO J art. 11 Industrial El Open Bottom 11 Manteca Dia. of Well Excavation Dia. of Well Casing Q ElC Domestic/Private ❑ Gravel Pack Tracy Type of Casing .Jrsy — Specifications ❑ Public 19 Other ❑ Delta Depth of Grout Seal .!0 Type of Grout-'eon J ❑ Irrigation - Zb—d—Approx: Depth ❑ Easternc�Surf ce Seal Installed by w (� Repair Work Done • LlType of Pump fNAS H.P. J State Work Done Well Destruction ❑ Well Diameter Sealing Material [top 50') Depth Filler Material ]Below 501 TYPE OF SEPTIC WORK: .NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ fNo septic system permitted if public sewer is available within 200 feet.] t 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_ t SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ 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 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 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." The applicant st call for all required inspections. Complete drawing o verse sided Signed Title: - ) )Z–t` Date FO EPARTMENT USE ONLY / Application Accepted by Date/0 Pit or Grout Inspection by �( Date s" Final Inspection by z�i Data�_l1 z7 - A ditional Comments: 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 AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO.' INFO CASH /// + EH 13-244REv. EH W26