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APPLICATION FOR PERMIT I 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 Ordinan a No.549 for ewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin { Local Health District. ♦� Tiaa�1.S ¢I Job Address + City Lot Size--CQ-eLc krc_ -5 PMCL 7 t Owner's Name a e10 IS 0, Address 1� �� OL f�) !! If�_0 ,7 G( Phone S,1 '12 7 Contractor Vdle-V I n Address J 2 r ` A icense No.`v� � Phone ry =aZz TYPE OF WELL/PUMP: NEW WELLX WELL REPLACEMENT Q DESTRUCTION ❑ k ^� ti PUMP INSTALLATION SYSTEM REPAIR F1 OTHER 3 DISTANCE TO NEAREST: SEPTIC TANK -�42 .� SEWER LINES DISPOSAL FLD. PROP. LINE f FOUNDATION AGRICULTURE WELL—"71—OTHER.WE_LL _ PITS/SUMPS -� INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS _ "'"� -� ❑ Industria! i�lC en Bottom ❑ Manteca Dia. of Well Excavation 6 i + Dia. of Well Casing 1 5Domestic/Private ❑ Gravel Pack E) Tracy Type of Casing :al- Specifications M Publics = f�" f) Other [7 Delta Depth of Grout Sea] f ' v P -'Z�._ T, ypqof Grouts I I Irrigation --Approx. Depth I Eastern Surface Seal Installed by �" ��c' Repair Work Done /U Type of Pump Z_ _-_ H.P, _� State Work Done_ Well;Destruction 0 Well Diameter Sealing Material Itop 501 Depth Filler Material (Below 50') E TYPE OF SEPTIC WORK: NEW'INSTALLATION I'1 REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence Commercial_ Other € ' Number of living units: Number of bedrooms Character of soil to a depth of 3 feet:- # { SEPTIC TANK ❑ Type/M1Rf9 - Capacity Water table depth No. Compartments PKG TREATMENT PLT. ❑. Method of Disposal 'r f i f A Distancetonearest: Well Foundation - Property.Line LEACHING LINE Q No: & Length of Eines Total length/size i FILTER BED ❑ Distance to nearest: Well Foundation Property Line LS F SEEPAGE PITS I I Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS EI ' I hereby certify that I have prepared this application and that the work will he done in accordance with San Joaquin county ordinances, state laws, avid rules and regulations of the San Joaquin Local Health District. 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 ust call for all required inspections.Complete drawing on reverse side. Sign�d Title: Date: i t FOR DEPARTMENT USE ONLY f� Application Accepted by y Date V9 LArea V Pit of Grout Inspection by Date Final Inspection by i �"1d1 Date f' a Additional Comments: ❑ Sfk 466-6781 Lodi 369-3621 ❑ Manteca 823-7104 4 ❑ Tracy-,835- 5 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E-Hazelton Ave., f.0":Box:2009, Sik., CA 95201 .. i .. ----^"-�"� _ INFO n AMOUNT DUE AMOUNT REMITTED CK RECEIVED t3Y DATE PERMIT'NO. .'/ C H S + EH 13.24 1REV.1 i a 5) ? EH 14.28 1 y i