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APPLICATION FOR PERMITs�a� , 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 Ordinance No. 549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address_?d� 7�r City °� Lot Size PM Owner's Name ress.3 o4os��1� 1r Phone J /- Contractor �e��Y�-tom &-�Address License No/4 23 22 Phon _ TYPE OF WELL/PUMP; NEW WELL WELL REPLACEME DESTRUCTION ❑ PUMP INSTALLATION X SYSTEM REP OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK Ed/ SEWER LINES 514 DISPOSAL FLD. PROP. LINE / FOUNDATION --. AGRICULTURE WELL OTHER WELL-3-0-L- PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS r r 1:1 Industrial L1 Open Bottom © Manteca Dia. of Well Excavati Dia. of Well Casing 0 Domestic/Private Gravel Pack ❑ Tracy Type of Casing � �� Specifications ezz., Public 1-1 Other r _ I-1 Delta Depth of Grout Seal f©B ., Type of Grout g, I I Irrigation —.-Approx. Deotq I I Eastern Surface Seal Installed by _ Repair Work Done Cl" Type of Pump H.P. /, State Work Done Well Destruction ❑ Well Diameter ' Sealing Material Itop 501 Depth G_ Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR/ADDITION l 1 DESTRUCTION l 1 INo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_____ Other Number of living units: Number of,bedrooms o Water table depth W Character of soil to a depth of 3 feet: �'. - k SEPTIC TANK ❑ Type/Mfg Capacity No: Compartments i PKG. TREATMENT PLT. ❑ i - Method of Disposal Distance to nearest: VQII Foundation Property Line (� ; LEACHING LINE% ❑ , No. & Length of lines. 1 { Tota! length/size FILTER BED —Distance-to-nearest:= N'Weil°�Foundation— �t� Property""Cine SEEPAGE PITS l 1 Depth } Size Number rt SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS © I i 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. Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the wofk for which this permit is issued, I shall not r 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 " fy performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." The applica must call for all r wired inspeEt ons. Complete drawing on reverse,side. ! p Signed X _( : % /�G tle: Date: I FOR DEPARTMENT USE ONLY Applicat! Accepted by Dated' Area� _ k Pit�;Go:utnspection by Date Final Inspection bqh��-- _ _ Date ' Ih Additions! Comments, ❑ Stk 466-6781 ❑ Lodi 369-3621 ' O,Manteca 1123-7104 ❑ Tracy 835-6385 i Applicant - Return all copies to: Environmental Healih Permit/Services 1601 E. Hazelton Ave., P.O.'Box 2009, Stk., CA 95291FEE i INFO AMOUNT DUE AMOUNT REMITTED CASH CK liF__ RECEIVED BY DATE PERMIT'NO. r EH 13-24(HEV.t/n 5) EH 14-26 ll 6J �r 7