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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE 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. 1852 for well/pump and the Rules and Regulations of the San Joaquin Local Health District... Job Address D 1 Lot Size+ PM tom; Owner's Name f AddressPhone K33_al� 133 Contractor's Name 5 57CApr6C— License No. 44 105 Is -- °�- Phone'S�/' TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ *,]]DESTRUCTION ❑ rte` ""' """`� ` ;' —PUMP "INSTALLATIOA! ❑ SYSTEM -REPAIR -L) - - OTHER -Cl --- r 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 SIPECIFICATIONS ` �- w CK ASH ❑ Industrial ❑ Open_ Bottom 'I] Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/ Private ❑ Gravill Pack �, ❑Tracy 1 Type of Casing r Specifications ❑ Publica ❑ Other ;❑ Delta t Depth of Grout Seal 4-- F Type of Grout G ❑ Irrigation _�lpprox. Depth �O Eastern Surface Seal Installed b, I - Repair Work Done ❑ Type of1Pump 'H. P. Staff .11Vork Done f * f Y` < !' 0% Well Destruction ❑ Well Diameter � �� Sealing Material (top 50') w. Depth *Filler Material (Below'50'1 - - - TYPE OF SEPTIC WORK: NEW INSTALLATION -13 PA ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) ""--ffi._ Installation will serve R ience Commercial ther i ��x' ✓ K--) r� ' _Number of living units:"' Number be rco sr Character of soil to a depth of 3 feet: *�'} Water -table depth SEPTIC TANK ❑ Type/Mfg` o.: Compartments PKG. TREATMENT PLT. ❑ �.�Metnod of D posal,` � - -- Distance to nearest: Well Foundation Property Line { : p ,LEACHING LINE No. & Length of lines �:.Totai'length /size FI!_TER BED. ❑ Distance to nearest: WellFoundation-------... Property.Line SEEPAGE PITS ❑ Depth ( Size r Number SUMPS ❑ ` Distance to nearest:" Well -Foundations Property'Line DISPOSAL PONDS ❑ t 'V I hereby certify that I have prepared this applica&66- hd that the work wiil be aone4n accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin6;d'Health District. , ia 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." ContractO-r,s-hiring'br sub -contracting signature certifies the following: "I certify that in the performance of the work for Which this'peimit is issued, I shall employ -persons -subject to workman's compensa- tion laws of California." T I - The applicant m st call for all required in cions. Complete drawing.on reverse side. Signed X Title: r Date: FOR DEPARTMENT USE ONLY Application Accepted by ` i V Date % _ / Area PR or Grout Inspection by Date Final Inspection by Date 0 �� Additional Comments: ❑ Stk 466-6781 ❑,Lodi 369-3621y� Applicant - Return all copies'to: Environmental H .+ Eli 13-24 IRM 10183 EH 14-28 Manteca 823-7104 ❑ Tracy 835-6385 th Permit/ Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED w CK ASH RECEIVED BY _DATE f ERMIT"N0. LKdo �r m � i