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APPLICATION FOR PERMIT " SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 9 YEAR FROM DATE ISSUED (Complete in Triplicate) i 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. 11362 for welUpump and the Rules and Regulations of the San Joaquin Local Health District. I f V {, City`� Tk G Lt Size.� ozPM I Job Address Lf Phone Owner's Name Address M �-7-��G l Contractor Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ l 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 C1Manteca Dia. of Well Excavation Dia. f Well Casing r y ❑ Domestic/Private CI Gravel Pack ❑ Tracy Type of Casing Specifications fl Public ❑ Other Cl Delta a Depth of Grout Seal Type of Grout -- I 1 Irrigation --Approx. Depth I I Eastern 'SL`rface Seal Installed by - Repaija.Wak,Ibone ❑ Type of Pump H.P. State Work Done r ,z.. r , Well;f�estructlon, ❑ Well Diameter Sealing Materia! Stop 50'l Depth t w 5011 ,r QTY-PE OFSEPTIC-WORK: NEW INSTALLATION EPAIR/ADDIT! 1+. DESTRUCTION I No septic system permitted if public sewer is «� YT available within 200 feet.) ,r I f '� Ihstalldtion wdi serve: Residence '� Commercial_ Other' �- �• ��• f '' Number of living units: 21 Number of bedrooms __— Character of soil to a depth of 3 feet: ' Water table depth 2-0 SEPTIC TANK ❑ Type/Mfg �� L C�+� �r P �.Capacity 1 7iQ�__ No. Compartments i PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line } LEACHING LINE L1 No. & Length of lines Total length/sizeIF �► FILTER BED Distance to nearest: Well Foundation .— Property Line 1Number r . SEEPAGE PITS l I Depth Size SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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.Loca! Health Diltrict. 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." k The applicant mus al for all required inspections. Complete drawing on reverse side.. Signed 0 � Title: — Al-'`'I�/�. Date: O "" F EPARTME T USE ONLY p Application Accepted by Date Area Pit or Grout Inspection by Dae Final Inspection by Date 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 95201 a S. FEE AMOUNT DUE AMOUNT REMITTED K RECEIVED BY DATE PERMIT NO. s INFO +.EH LID 53-24 IREV.t/m5) �, / Ioo� J� �• i EH 14.26 y- as