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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVL., 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. 1662 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address/ L � City Lot Size / G PM Owner's Name �MA 1/l9 Address B Contractor ess�T 1 � License No. Phone TYPE OF WELL/PUMP: N WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATII�O,N,ff � SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK tSEWER LINES l� DISPOSAL FLD. '�— PROP, LINE FOUNDATION -_75—._--..- AGRICULTURE WELL OTHER WELL PITS/SUMPS I INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS �r [I Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing IwDomestic/Private Gravel Pack ❑ Tracy Type of Casing �� Specifications + r7 Public F] Other ❑ Delta Depth of Grout Seal /Xt2 Type of Grout I i Irrigation .2pprox. Depth l.�I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump 152 2 H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material {top 50') - Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION 1 1 REPAIR/ADDITION l I DESTRUCTION I l (No septic system permitted if public sewer is available within 200 feet.) it Installation will serve: Residence_ Commercial_ Other 'r Number of 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 Line �1 L i T LEACHING LINE ❑ No. & Length of lines Tota! length/size FILTER BED ❑ Distance to nearest: Well Foundation. Property Line SEEPAGE PITS I 1 Depth Size 3 Y ? Number ' F SUMPS ❑ Distance to nearest: Wel! 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 r rules and regulations of the San Joaquin Local Health DFstrict. a r' Home owner or licensed agent's signature certifies the following: '9 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'Califomia." 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." t The applicant st I qui r s. Complete drawing on rove rse/rde. Signed X vA�_ Date: / OR DEPARTMENT USE 0146Y 7 / Application Accepted by Date Area /"& l �.. .... �a �� f2 � f Pit o Grout I spection by Date Final Inspection by Dated i Additional Comments: C �G(g �P/ t a,- L 011- k-0 I/d ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Mantec 7104 Tracy 635-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 d 4 INFO AMOUNT/DOSE AMOUNT REMITTED CASH RECEIVED BY�, DATE PERMIT'NO. . EH 13-21(REV.I K5) �. + F -�a�D V x_14 y EH 11-24 t 9� � r