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APPLICATION FOR PERMIT 1 SAN JOAQUIN LOCAL HEALTH DISTRICT S 1601 E. HAZE i ON AVE., STOCKTON, CA f Telephone (209) 466-6781 PERMIT-EXPIRES 1 YEAR FROM DATE ISSUED l; (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. 2S 7 Job Address l 1'f~Lc• Cit Q� Lot Siz PM , Owner's Name -1 Jl�� - Address s� Phone S33--O a©O r C-O > r .S 72 Z Phone �� /�S ,;Contrac Address License No. -TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ J! PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER I❑ I 1 _ _DISTANCE TO NEAREST: SEPTIC TANK —.SEWER LINES R __ DISPOSAL FLD. -PROP. LINE, _ t FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS ._ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS t i ❑ Industrial LJ Open.Bottom L1 Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications 1 If`l Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout _ 'I i Irrigation ----.Approx. Depth I 1 Eastern Surface Seal installed by _ Repair Work Done 0 TypeofPump,`. H.P. State Work Done Well Destruction ❑ -Well Diameter *` Sealing Material (top 50') li Depth ler Material {Below 501 TYPE OF SEPTIC WORK: , NEW INSTALLATION 11 EPAI !ADDITION.15<DESTRUCTION 1.1 INo septic system permitted if public sewer is N *� x ;available within 200 feet.) e - i Installation will serve: Res_._Ience— Commercial Other y Number of living units: "~`� Number of aoms II Character of sail to a depth of 3 feet: Water table depth 0 1A • r I SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments IPKG. TREATMENT PLT. ❑ e4f r Method of Disposal J Distance to nearest: Well Faunation Property Line (h LEACHING LINE. El No. & Length of lined Total length/size FILTER BED ❑ Distance to nearest: Well F1oundation Property`Line VEEPAGE PITS Depth Size tNumber { Cl :Dr St7MP5 io stance to nearest: ^rWelE� Foundation � Property Line—A ._ I DISPOSAL PONDS ❑ 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, rules and regulations of the San Joaquin Local Health Di1trict. 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--,t\ -tion laws of California." F The applican st call fot quir inspections. Complete drawing on reve1rs,si 7O/-c4 94J :.Signed X Title: V 1 Dater FOR DEPARTMENT USE ONLY LJ Application Accepted b� Dater rF6Area 12 r Grout Inspection by ate �27�/r7Final Inspection by / � Ge-s� Date i Additional Comments: i i❑ 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 95201 FEE i INFO AMOUNT DUE AMOUNT REMITTED CASHi CK RECEIVED BY HATE PERMIT'NO. °i +.EH 13-24 TREY.i/a 53 =F EH 14 � 25 �,-- d C3` y