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f �i 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 Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. , 1 1 Job Address Z3 / G City . - �e,�- Lot Size PM Owner's Name Address 1� G �i'�-t Phone � Photor's Name UM� 41.L License p TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT DESTRUCTION I PUMP INSTALLATION YSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK ~lb SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELLI-0 PITS/SUMPS INTENDED USE i TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIO S �y ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation 10 plfk Dia. of Well Casing O p� Domestic/Private ❑ Gravel Pack ❑ Tracy, , Type Q I P' yp of Casin g .� �1Z, Specifications ] i k* i ❑ Public *Other ❑ Delta Depth of Grout Seal df � `r Type of Grout }� r ❑ Irrigation 4 --Approx. Depth ❑ Eastern Surf ce Seal Installed by S r Repair Work Done` ❑ Type of Pump _.)5A,'Pi__ H.P. �3' State WLO or Done -. S Well Destruction Well Diameter idl Sealing Materiel ifop 50;1h ; I II Depth ? Filler Material (Below 50') ' a i TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic syst€rn permitted if public sewer is 4 available within 200 feet.) Installation will serve: Residence— Number esidence_Number of living units: Number of bedrooms Character of soil to a depth of 3 feet:. f- Water table depth 1 SEPTIC TANK j ❑ Type/Mfg" r b ' .n.f '' Capacity " § No. Compartments PKG. TREATMENT` PLT: ❑ "^"" Method of Disposal 9 Distance to nearest: Well Foundation Property Line } ` _ a l LEACHING LINE ❑ No. & Length of lines,` -- Total length/size � FILTER BED z r❑ Distance to nearest: Well I LF.oundation Property Line P SEEPAGE PITS � '❑ Depth Size Number SUMPS ❑ Distance to nearest: Well 1-**" )Foundation -v- ' Property Line + DISPOSAL PONDS ❑ t 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 District. i -•—Home oJanpe icensed%agent's-signature certifies the following:-',4 certifythat in the-performance of the work'for-wt ich this-permit-is issued, I.shall not _ employ on in suckfthat as to bome subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifieswing: "I i th rform ce of the work fo`r which iFiis permit is iss-ued; I shall employ persons subject to workman's compensa-tion lawornia." The appust call f 'ed s ction . Complete drawing on reverse wide,,. Signed Title: Date: FOR DEPARTMENT USE ONLY Application Accepted by Date Area r / Pit or Grout Inspection by Data 9 Final Inspection by atew Additional Comments: ❑ Stk 466.6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201FEE 1 INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PE,RMIT'NO. +EH 13-24 EH 14-261REV.101831 .. �3 l3 g`i `,oq