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APPLICATION FOR PERMIT J- v µ �_ SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E'. HAZEL iON AVE., STOCKTON, CA T, Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED _t (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. Jab Address �D�h�� zT '-"' City Lot Size ` p / J Phone Owner's Name f��-IA�t� +�� Q- Address 1 � �� i s��296 ,� win �� o .r � Contractor y Address License No. Phone TYPE OF WELLIPUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION )0 SYSTEM REPAIR El OTHER I-] DISTANCE TO NEAREST: SEPTIC TANK jab t SEWER LINES DISPOSAL FLD.W — PROP. LINE FOUNDATION 35 — AGRICULTURE WELL .. — OTHER WELL___t,__ PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS tou 4 ElIndustrial LlOpen Bottom ❑ Manteca Dia. of Weil Excavation . 16" - Dia. of Well Casing-- € Domestic/Private Gravel Pack ❑ Tracy Type of Casing 'Sha r Or PVC,300 Specifications L V I r ❑ Public ❑ Other ❑ Delta Depth of Grout Seal b� Type of Grout i ❑ Irrigation & Approx. Depth LJEasternSurface Seal Installed by, l Repair Work Done 171 Type of Pump 51u H.P. State Wvrk Done Well Destruction ❑ Well Diameter Sealing Material atop 50'1 ' 6' k ` Filler Material-(Below 50'1 Depth G TYPE�OF SEPTIC WORK: NEW INSTALLATION El REPAIR/ADDITION 'DESTRUCTION (7INo septic system permitted if public sewer is R _ Y available within 200 feet.l r € installation will serve: Residen"-ce A_ Commercial_ Other k ! Number of living units: Number of bed oomsl=-� i . �71 I Character of soil to a depth of 3 feet-. a Water table depth r M».�« ,, Ie.�.r.c ZDOD No. Compartments- SEPTIC?ANK ❑ Type/Mfg`C0 Capa ity �� a .t� f i C00S 'Irl Method of Disposal PKG. TREATMENT PLT. ❑ J 1 3 " -A Distance to nearest: Well iQ� Foundation Property Line — LEACHING LINE ❑ No. & Length of lines - r Total length/size 3 t FILTER BED ❑ Distance to nearest: Well Foundation 261A— Property Line� I SEEPAGE PITS ❑ Depth's Size - Number SUMPS' Distance to nearest: Well ••.:Foundation- Property Line 1 '. DISPOSAL PONDS ❑ I ` I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin'co'-linty bldinances, 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 fallowing: "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." " s t The applicant m a for all re uir spec ons. Complete drawing on reverse side. j fJ Title. � Date: " Signed Ie I FOR DEPARTMENT USE ONLY , I Area Application Accepted by f,PiNtl IDate F al Inspec on b Date Pit or,Grout__Inspection by ► s Additional Comments: ❑ Stk 466-6781 Lodi 369-3621 ❑ Manteca 823-71 ❑ Tracy 835-6385 ,C Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box tk. CA�95201 f(J b� W FEE I AMOUNT DUE. AMOUNT REMITTED 0 RECEIVED BY DATE PERMIT'NO. INFO + EH 13-24 1 REV.1/8 5) DUH 5 1-7 6, in c� 350 EH 114-25 ~P