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` APPLICATION FOR PERMIT f 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 Ordiriance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District, I 5 S�r �r Job Address, Her City Lot"Size PM _ ff.� /� Owner's Name �' Urn "� Address 222 �/ 1' Phone 9� -3g] 7 /� f 6330 Contractor �fr ►Cr/ « Xp�� — �I - Address E�65CH� G License No. Phon q/6 TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYST M REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK �� SEWER LINES ,,deJb DISPOSAL FLO.�Ik�PROP. LINE Uh,eZgloklA FOUNDATION h_ AGRICULTURE WELL _LI±� OTHER WELL�4a 1,0 PITS ISUMPS(X A11W-J INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Ria. of Well Excavation g Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy .Type of Casing-W. X/�l�� Specifications n ('1 Public 'Other i"tOMI>a'Drf�(� .❑ Delta Depth of Grout Seal — 7� Type of Grout I I I irrigation _Approx. Depth l I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump K H,P. State Work Done 1 Well Destruction ❑ Well Diameter` 4117 ''- Seating Material (top 50') 29?md _ --E Depth Filler Material (Below 501 (n TYPE"OF SEPTIC WORK: NEW INSTALLATION I] REPAIR/ADDITION I I DESTRUCTION 13 (No septic system permitted if public sewer is available within 200 feet.► ` Installation will serve: Residence_�. Commercial_ Other ILA Number of living units: {;lumber of bedrooms t� Character of soil to a depth of 3 feet: Water table depth v� ; SEPTIC TANK ❑ Type/ f YP 9� Capacity No- Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line . � I LEACHING LINE ❑ No. & Length of lines Total length/size hFILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth I Size Number SUMPS 0 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 Di§trict. c i 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." The applicant call for all re uir if q peA�so'.plete drawing on reverse side.Signed XTitle: 4 Date: € I FOR DEPARTMENT USE ONLY Application Accepted by Date Area C Pit'or Grout Inspection by Date Final Inspection by Date i Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3521 ID Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environ ntal Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK yRgCEIVEf) BY DATE pERM17'ND. t«{ INFO q /�}� CASH j rRJ EI "'i-.EH 14-24{REV.1 H 51 � `�-/V r`��/r- 174, tl 1�{/rL,�, .�j. (,* ll�• 1 EH t4-28 r �l ` !