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APPLICATION FOR PERMIT 'hu SAN JOAQUIN LOCAL HEALTH DISTRICT J 1601 E. »AZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES°1'YEAR FROM DATE ISSUED I (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. 1862 for well/pump and the Ruies and Regulations of the San Joaquin Local Health District.1 5;LCtCT t/ -�_(t&J ")A-Y C � +j,,/ 0 6 r/--�,i0^ 4 Job Address u l o-,h IS l and I _ City Lot Size PM Owner's Name e 1 � Address bl o '? f \ - hone`'� .r rC1 O Contractor r Aijd�ss 3�7� Pato License Nona( hone TYPE OF WELLIPUMP: NEW WELL. WELL REPLACEMENT ❑ DESTRUCTION L PUMP INSTALLATION 0 SYSTEM REPAIR ❑ OTHER 0 r� DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES nUJO_ — � DISPOSAL FLD.�P TSP. LINE i2oV�e- FOUNDATiON y_ls.[_[ lr� AGRICULTURE WELL 160 THER WELL�rne INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial 0 Open Bottom ❑ Manteca Dia. of Well Excavation /-�,n Dia. of Well Casing VV(, y� i--�0 Specifications G Domestic/Private Q Gravel Pack F[ Tracy Type of Casing Type of Grout�� OYf1 s. J 1 PublicQOther Delta Depth of Grout Seal 1r- YP - R A rox. Depth I I Eastern Surface Seal installed by SemI� `lam l i r nr act n PP P W State Repairk Done Ll Type Type of Pump grk Done / Well Destruction ❑ Well Diameter Sealing Material (top 50'1 Depth Filler Material (Below 50') �� -- �- i I TYPE OF SEPTIC WORK: NEW INSTALLATION I l REPAIR/ADDITION l 1 DESTRUCTION I I 3vailabetrwitflin 200 feetsystem trled if public sewer is � }rL� Installation wilt server Residence— Commercial— Other ^� Number of living units: Number of bedrooms 1 Water table depth Character of soil to a depth of 3 feet: SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments C Method of Disposal' PKG. TREATMENT PLT_iL : :•-•�. r Disnceto:nearest f. Well F Foundation Property Line ta LEACHING LINE ❑ No. &•Length of'lines Total lengthlsixe r'"' ,ryre• FILTER BED._,....._ _.._ ❑ Distance to nearest:..,_ ,Well Foundation Property Line 1 i, SEEPAGE PITS- - I I Depth Size Number y i SUMPS 0 Distance to nearest: Well Foundation Property Line},�z l 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 District. Home owner or licensed agent's signature certifies the following: "1 certify that in the performance of the work for which this permit is issued, I shalt nor+r) employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting ggn�tl q f i 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,BA s cion laws of ornia-" _ The appli t ust call for requ tions. Complete drawing on Signed Title: Date: k FOfi EPARTMENT USE ONLY { e Area Application Accepted by Dat — / I Pit or Grout Inspection by Date Final Inspection by Date� 9 II y Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 0 Manteca 823-7104 0 Tracy 835-6385 Applicant- Return all copies to: Environmental Health PermitJServices 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. INFO CAS��H//�� 1 vnt 9 . EH 13.24IREV."951 �D_o � �0i36 I`` tH 14.26