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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 I PERMIT EXPIRES T 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- Job Address �< &� � City Lot Size 4� PM s o Owner's Name ��sa C.Cf /ll�i Address Phone f / ��Z _ i Contractor�_ tyo Address f f�f / Orr License Nv. .� � Phone_ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑, PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ ' 11 1 DISTANCE TO NEARtST:'SEPTIC TANK' `� SEWER LINES DISPOSAL FLD- PROP- LINE -- .-z A " - - FOUNDATION`= -- GRtCiJLTURE-Wff= """'� _fFfER-VIrE{L- -��"='PITS7SUMPS= � INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS r ,Cl Industrial 1) Open Bottom El Manteca i Dia-of Well Excavation + Dia. of Well Casing .11 Domestic/Private ❑ GravelPack''-'t ❑ Tracy' Type of Casing ` �,- i Specifications i 'Fl Public t 1 -,[-,),Other F1 Delta`_ _Depth,of Grout Seal Types of Grout _ t I i Irrigation, Approx. Depth t.I 1. Eastern] �.. Surface Seal Installed by, I Repair Work Done El Type of Pump - - -.H.P. `� :. - State Work Done. 7 . Well destruction ❑ Well Diamefdr Sealing Material,(top 50') . } Depth A Filler Material l8elow 501 I TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION i I DESTRUCTION { I (No septic system pefmitted iF public sewer is € available within 200-feet.) `/ ( ft I Installation will serve: Residence r. Commercial Other ' • i r 1 r I Number of living units: _/— Number of bedrooms ICharacterl of soil to a depth of 3 feet: k ' �: 1�0 A► +�, �*F u� Water table depth SEPTIC TANK ❑ Type/Mf'g? Capacityy_ No.,.Compartments PKG. TREATMENT PLT- ❑ ` r �� r Method of D'sposal { Distance to nearest: Well Foundation I ! �- _— Property Line � 1[ 'LEAd NG LINE 1 No. & Length of-lines — --� s Total_length/size 1 .FILTER BED ❑ Distance to nearest: Well ¢ Foundation 7/`�`Property Line - SEEPAGE PITS 11 Depth i FT SUMPS j 0Distance to nearest: Well Foundation_2& _ Property Line�.__ DISPOSAL PONDS ❑ 1' l hereby certify that I have prepared'-this application and that the work will bb done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health Di$trict. l t' Home owner or licensed agent's signature certifies the following �S_ , I g g g: "I certif -that q ikig�erformance of the work for which this permit is issued, i shall not kJ employ any person in such manner as tobecome subject io workman's compensation laws of California."Contractor's hiring or sub-contracting signature *A 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- V I tion laws of California." i + The applic nt must call for all qui inspec' s.;Complete drawing onrse Bide. S. Signed X c - Title: Date- a FOR DEPARTMENT USE ONLYI , Application Accepted by ! 5 f Date 101 V_> G-l' Area v .,/.._ -mak �10Pitpr,Grout Inspec.tion.by - '`' Dater Final Inspection by I Additional Comments: IJ Stk 466-6781 ❑ Lodi 369-3621 O Manteca 823-7104 ❑ Tracy 835=6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Ha eltorl"Ave., P.O. Box 2009, Stk., CA 95201 i INFO AMOUNT DUE AMOUNT REMITTED CA6H It RECEIVED BY 4 DATE PERMIT NO. I +l EH 13-24(REV,185) J - -EH 14-2a y Q 1, ! }