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i APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA J „I n 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. t� �� Cit Job Address Y Lot Size PM ��111 p Owner's Name h� I� iv��r Address qq Phone antractor A64dtlress_5____ ?e& _BO—M License IVa" Phone TYPE OF WELL/PUMP: j T NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR ❑ �OTTHER ❑ � DISTANCE TO NEAREST: SEPTIC TANK /GA�Y//� SEWER LINES 1t�O tf' DISPOSAL FLD.L/w � . PROP: LINE C-30 FOUNDATION ALL— AGRICULTURE WELL iUXJe-OTHER WELLAT PITS/SUMPS r INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom: ❑ Manteca Dia. of Well Excavation Dia. of Well Casing i , .Domestic/Private Gravel Pack ❑ Tracy Type of Casing e,�lf7l�_ Specifications F'3 Public ❑ O`ther F1Delta Depth of Grout Seal Z� Type of Grout 1fi I I Irrigation d-Approx. De th ,tel 1 Eastern Surface Seal installed by _ Repair Work Done Type of Pump rl� H.P. �1� —_ State Work bone Well Destruction ❑ Well Diameter Sealing Material atop 50'1 De 11 h Filler Material (Below 50') _ TYPE OF SEPTIC WORK: NEW INSTALLATION I] REPAIR/ADDITION i 1 DESTRUCTION i I (No septic system permitted if public sewer is I` { -'available within 200 feed Installation will serve: Residence_ Commercial_ Other Number of living units: Number ofbedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ rType/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line `rte IM LEACHING LINE U jNo. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I IDepth _ Size Number F 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.Galifomia." 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 subiact to workman's compensa- tion laws of California." The applicant ca or all�re u' inspect: ns. Complete dr a ing o arseside. ,� f Signed X l� Title: 7= /� `[ / Date: / FOR DEPARTMENT USE,ONLY �! Application Accepted by 1 '1 1 _ Data "` Area r. Pit or Grout Inspection by� Date'�~ nal.Inspection by ` Date Additional Comments: I j ❑ Stk 466-6761 ❑ 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' '�AMdbN DSD UE`�'y —AMOUNT REMIT ITTED RECEIVED B� DATE PERMITNO. INPO ASH r.EH 13-24 1REV.t/11 51 I[F 7� M �A 6— �]�7t EH 14-26 / C7