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E) I� APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 7 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.'TNs application is 9 made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Ryles and Regulations of the San Joaquin ! Local Health District. Job Address / �5x r City li! LotrSize PM Oler's Nam D ddress L90Phone j Contractor Address �� /�49X__� License NoZrV3f3 Phone r TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT-0 DESTRUCTION ❑ DIIt' PUMP INSTALLATION 11 SYSTEM-REPAIR LJ OTHER ❑ ANCE TO NEAREST:,SEPTIC TANK SEWER LINES `��• DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS ' €INTENDED USE +iPE OF WELL-' PROBLEM AREA CONSTRUCTION SPECIFICATIONS OIndustrial 1] Open'Bottom 1=J Manteca } Dia. of Well Excavation Dia. of Well Casing " ❑ Domestic/Private ✓'©Gravel Pack ❑ Tracy Type of Casing t � Sp � e�fications ElPublic ❑ Others El Delta Depth of Grout Seal a Type of Grout .'p q. � ❑ Irrigation 0 ---Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done D Type of Pump H.P- _State Work Dane Well Destruction ❑ Well Diameter Sealing Material {top 501 r Depth Filler Material (Below 501 t i TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION DESTRUCTION 0:6(No septic system-permitted if public sewer is available within 200 feet.) (y' 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- - u SE k IC TANK ❑ Type/Mfg CapacityAVC�H No. Compartments Z PKG. TREATMENT PLT. ❑ :� Method of Disposal. ._ —Distance to nearest: Well Foundation. � Property Line J i J LE ICHING LINE '�^-^r�No'& Length of lines"' f j " Total length/size oz 5 FILTER BED ❑ Distance to nearest: Well add Foundation_/Ot_._ Property Line SEEPAGE PITS L Depth Size 3�E� "Number xt ` f _ SUMPS. ❑ Distance to nearest: Welt//JO Foundation �_1049 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." Th eF app an II for aR reqire inspections. Complete drawing on reverse st e. n f° �� Signed Title: Date: 1 FOR DEPARTMENT USE ONLYF !i, Application Accepted by Date / Area Pit-or Grout Inspection by Date 4 r465 Final Inspection by Date-1 i Additional Comments: _46676781 ❑ Lodi-,VS-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 ii )NFO AMOUNT-DUE AMOUNT.REMITTED CASH RECEIVED BY DATE PERMIT"NO, f� rr +EH 13-24'{REV-7/e 51 EH 14-26 _ �iJ 0 u j ��l��S Ys 3� , - 1"