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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICTFIvVii . ' 1601 E. HAZELTON AVE., STOCKTON, CA uJ All. r V Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED_ (Complete in Triplicate) Application is he eby 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 Job Address H"+'7 w• lJ 1 E�."/� �Wf� City_6�_Ow Lot Size PM "TeA Owner's Name _ jzrjl✓/1,K7 �ru%'�f/i' .lYgddr ss l h 7r✓(� (`�lr�T.ff� �(11 L/i'I'Y'Ill"rho o 'L`l R_ � 1s7/IC7/c��N Contractor 7 'x Address //k U�t License tio. - z Phone TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHERfig.y L_L DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE 77' FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 1.1 Industrial 150P n Bottom ETManteca Dia. of Well Excavation .Lei Dia. of Well Casing I I Domestic/Private /Gravel Pack ❑ Tracy Type of Casing PVC -'I,� iWel - � Specifications �, I I Public I Other IN Delta Depth of Grout Seal -fi /.. r "n' Type of Grout t ✓1[1_{e;- 'L, I I bngaiion ___ Approx. Depth I I Eastern Surface Seal Installed by ('nK;1QAC?'t_J 1Z Repair Work Done ❑ Type of Pump H.P. State Work Done We,I Destruction ❑ Well Diameter Sealing Material (top 50'1 L�. I11I oR.fni4 ajLL Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is h available within 200 feet.) Installation will serve: Residence_ Commercial_ Other C Number of living units: _ Number of bedrooms Character of soil to a depth of 3 feet: (1 p --- Water table depth_ SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments _ t PKG. TREATMENT PLT. ❑ Method of Disposal _ Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size \� FILTER BED Cl Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size __ ______.__ Number- SUMPS L I Distance to nearest: Well Foundation Property Line DISPOSAL PONDS L7 I hereby certify That 1 have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, anti C rules and regulations of the San Joaquin Local Health Diltrict. 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 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 Caldor ia." The applicant st call for all r it d ins t' S. Complete drawing o reverse sipe. Signe ' �� Title: �7C� S Date: r �7 FOR DE �MENT 5 LY \ !i Application Accepted by .� _ Date �,C / Area, - Pit or Grout Inspection b /"� Date`s�-,l/ Final Inspection by. % '�- �• / Date, Additional Comments: ❑ Sik 4666781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 635-6385 i Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 [FEE AMOUNT DUE AMOUNT REMITTED INFO CASH RECEIVED BY DATE PER MIT'NO. . EH 134E(REV.I n hi