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2 L APPLICATION'FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON 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. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. 0 -A <-/ 5^ Sdfrt_ 7]S tit f r.. /AQ 10d 1 .,e Si7a PM .roc Aouress - _ �. t - - ,.,.T --- --- — BY /r Address '� Sh 5 S 61 . Phone Owner's Name -V--2> S, 9 !� j �7 / b � 7S VVLicense No.'33 7r 3 Phone 2- Contractor Address. j&> - TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT L1DESTFFUC_TfON PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ 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 SPECIFICATIONS • Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/ Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications Fl Public n Other 17 Delta Depth of Grout Seal Type of Grout _ I I Irrigation _.-Approx. Depth I 1 Eastern Surface Seal Installed by - Repair Work Done D Type of Pump H.P. State Work Done Well Destruction I Well Diameter -ALL-11AL Sealing Material (top 501 �7 d ` Depth s Filler Material f Below 501 614 TYPE OF SEPTIC WORK: NEW INSTALLATION I1 REPAIRIADDITION I 1 DESTRUCTION I 1 iNo 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 0 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 SEEPAGE PITS 1 1 Depth Size Number SUMPS L1 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: "t 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 certi y 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 ia." The applic nt us I f al required inspections. Complete drawing on reverse side. Signed X Title:ry c�[J P J'�P Date: IC7 LFOR DEPARTMENT USE ONLY _�` Application Accepted by C2& —11 Date / ` " Areae Pit or Grout Inspection );�: �__ by Date Final Inspection byOfj ty9$- - DatQA'21.- Additional Comments: 0 Stk 466-6761 ❑ Lodi Applicant - Return all copies to ♦ EH 13-24IREV.1/85l EH 14-26 369-3621 ❑ Manteca 923-7104 ❑ Tracy 635-6385 Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 955201 FEE INFO AMOUNT DUE AMOUNT REMITTEDRECEIVED BY DATE PERMIT' NO. -V--2> S, 9 ►"/zb �F �r�� 91 11 LN IA 6