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w APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 AtJ p PERMIT EXPIRES 1 YEAR FROM DATE ISSUED [fLer (Complete in Triplicate) /'- Application is hereby made to the San Joaquin Local Health District for a permit to construct and/of 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 371']1l l-a Tl o �.z� City Lot Size PM Owner's Name /"/Y/ d�0 J2_/U�Address 7l0 7 MIPGr.E-74� /ZO Phone Contractor Address v�C J �Uf.L�Gid License no. -Phone 75 TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ / DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES r' DISPOSAL FLDf— PROP. LINE r FOUNDATION AGRICULTURE WELL .�- OTHER WELL . PITS/SUMPS a - INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <'1 ❑ industrial I ❑ Open Bottom ❑ Manteca Dia. of Well Excavation r Dia. of Well Casing �'� l/_0 DomesticlPri�ate ravel Pack ❑ Tracy "�, Type of Casing- Specifications---�r.ri.� R Public'-"y n Other ❑ Delta Depth of Grout Seal M10/' h Type of Grout'�/y�"O I 1 Irrigation �W_Approx. Depthi Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump :54&U-_ H.P. State Work Done Well Destruction Q Well Diameter Sealing Material (top 50') �� Depth Filler Material (Below 501 �l 1, TYPE: OF SEPTIC WORK: NEW INSTALLATION f 1 REPAIRIADDITION I ] -DESTRUCTION I I fNo septic system permitted if.public sewer is within 200 feet._) Installation will serve: Residence— Commercial—""'Other: Number of living units: Number of bedrooms- Character edrooms Character of soil to a depth of 3 feet: z `� moi. " Water table depth N�) SEPTIC TANK ❑ Type/Mfg Z _ Capac'ity No. Compartmental PKG. TREATMENT PLT. ❑ i Method of Disposal m Distance to nearest: Well-' 'Foundation Pyperty Line t �] LEACHING LINE ❑ No. & Length of lines ' Total length/size e i FILTER BED O Distance to nearest: Well I RFoundation. Rroparty`Line— SEEPAGE PITS i I Depth Size Number' _ SUMPS 0 Distance to nearest: Well Foundation x Property Line DISPOSAL PONDS ❑ _ I hereby certify that I have prepared,this application.and that the work will k e done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health District: 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." y I The applicant Tc�Va'1,;4equJre ns. Complete drawing on raver ide. /�� Signed X ills: Date: b j� FOR DEPARTMENT USE ONLY J Application Accepted by / r ' Date/ 0 Area Pit or Grout Inspection by Date-- Final Inspection by Date Z-z Additional Comments +y ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca -7104 ❑ Tracy 835-6A5 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE(NEO AMOUNT DUE AMOUNT REMITTED CK CASH RECUVED BY DATE PERMIT'NO. +.EH1 3_14(REV.�/H5) P 7-to EH 14.26 �✓ L./" ��'!' 1 -