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APPLICATION FOR PERMIT SAN JOAQUIN,LOCAL HEALTH DISTRICT y - � � 1601 E.,I AZEL T OWAVE...,, STOCKTON, CA Telephone (209) 466-6781 t PERMIT EXPIRES 1 YEAR FROM DATE ISSUED UL% 0111 X31313 (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the ItA application is made in compliance with Sari Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and the RuppSEf r� Thai San Joaquin Local Health District. �]Al. / aYt Job Address f Cit nt Size PM ',dress �� Own 's Name 1 �–Cr CPone II ddress ox t � icen eYN. Phone Y Contract r W TYPE OF WELL/PUMP: ti NE WELL ❑–/ a� WELL REPLACEMENT ❑ DESTRUCTION 11PUMP INSTALLATION C� SYSTEM REPAIR ❑ R OTHER ❑ DISTANCE.TO NEAREST: SEPTIC TANK SEWER LINES _ DISPOSAL FUD. PROP. LINE a ! FOUNDATION AGRICULTURE WELL OTHER WELL_____i__ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ° ❑ Industrial ILI Open Bottom ❑ Manteca'. Dia. of Well Excavation + Dia. of Well Casing i ,� � 1 L Domestic/Private LIGravel Pack 0 Tracy Type of Casing Specifications in Fl Public I_l Other ❑ Delta # Depth of Grout Seal Type of Grout Y N I I Irrigation ti �TM _Approx. Depth I 1 Eastern Sl ace Seal Installed by / S tw State Work Dane VO Repair Work Done r tT Type of Pump H.P. T s Well Destruction ❑_Well Diameter Sealing Material (top 501 Depth' ✓- – f Filler Material (Below TYPE OF SEPTIC WORK: NEW INSTALLATION I7 REPAIR/ADDITION t I DESTRUCTION (`I' (No septic system permitted if public sewer is t available within 200 feet.) Installation will serve: Residence Commercial— Other Number o1 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 Lime LEACHING LINE Cl No. & Length of lines Total length/size FILTER_ BED ❑ Distance to nearest: Well Foundation Property Line . I SEEPAGE PITS l I Depth Size Number SUMPS\ Cl -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 per in su manner as t become t to workman's compensation laws of California." Contractor's hiring or sub-contracting signature i certifies the f owing: "I c ify that in t# man of the work for which this permit is issued, I shall employ persons subject to workman's compensa i tion laws o Caiif nia." The appli for all; ns. CgRlplsttr drawing on side. Wf S-z 3 - f2 i Signed X r - Title: Date: ---TOR DEPARTMENT-USE-ONL.Y`,.. Application Accepted by x , s_ 1 ', �,t`,,Date ��j or Grout Inspection b 71— PitFinal Inspection by h `.1' � Date y Additional 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 95241 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. INFO a CASH n yell + EH 13-241REV.I/x51 �S S•�(� G� —5—fo Lo— 1Af/3 EH 14-26 J ..