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r-. APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZETON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED DIS 1001 (Complete in Triplicate) t1F,A.� OjNfl5ION Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or inst Wherein describ is application is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for welIXRVM�AN $#0"and ReBjfl t��f the San Joaquin Local Health District. l J� gt Job Address Dom© " �'� orrjrd'r,��ocy/� �.�// qG City �7t2GI��b�Y Lot Size PM Owner's NameY�l�`'/1/� r/ Address /`-' '� / V- / G//�1�-- Phone Sell— Contractor g1Z.__t%/�—l�/ ' Address �j l�� rGrt ea License No.O�-_f37 Ph =! TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION-ffr— SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK �� SEWER LINES 7,.r DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATION ndustrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private W-11—mvel Pack ❑ Tracy Type of Casing ST e�� Specifications A(ea7` M Public I_-;�ther)WAW�NY' ❑ Delta Depth of Grout Seal _'y�7 � Type of Grout Q I I Irrigation --Approx. Depth l I EasternS�rrtace Seal Installed by lc�v�-ter wil/x*► �/La� Repair Work Done Ll Type of Pump [/fly H.P. / Z State Work Done Well Destruction ❑ Well Diameter Sealing lVaterial Itop 501 Q Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION l I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) 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 5 SEEPAGE PITS l I Depth Size Number .s' SUMPS Ll 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 ordir� state laws, and` rules and regulations of the San Joaquin Local Health Di§trict. .C�V,�I� 10 Home owner or licensed agent's signature certifies the folkowing: "I certify that in the performance of the work fQ s(�bff R is issued,•f shall not/t employ any person in such manner as to become subject to workman's compensation laws of California."1Ctc�rttfac'i Esic�h b-contracting signaturJ certifies the following: "I certify that in the mance of the work for which this permit is issued, lfstta�4@mplay pesgg '10'workman's compensa tion laws of California." N 10N �' The applicant t call fo inspections. Complete drawing on r er side+eNLY� _4 Signed X r Title: Date: FOR DEPA TME U Applic Jtion Accepted by Date Q Area Pit or Grout Inspection by / Date ! Final Inspection by -^ Date Additional Comments: ( �1 � � Ctib '✓�`-G ��/ e 6r,6 147,e� ❑ Stk 466-6781 O Lodi 369-3621 ❑ Manteca 82 -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 INFO AMOUNT DUE AMOUNT REMITTED CASH CK 4 RECEIVED BY DATE PERMIT NO. +.EH 13-24[REV. /H 5) —ep-- 3s .00 (o y.3s 3 3-?y ?I-Y.?3 EH 11-I6