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APPLICATION FOR PERMIT SAN JOAQUIN LOCACHEALTH DISTRICT I II 1601 E. HAZEL I ON AVE., STOCKTON, CA Telephone 5209] 466-6781 I� PERMIT EXPIRES 1 YEAR FROM DATE ISSUED I _ (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.Tins application is made in compliance withSan Joaquin County Ordinance No.549 for sewage or No. 1861 for well]pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address - I L.t C•rts�' �J � ,1.� !-�a Dy �} Lot Size /PM {� Owner's Name fE Address _ [ r �l ,•-1�• Phone ` Contractors Name4—V .- •C !cense No. N t Phone t3 { TYPE OF WELL/PUMP: NEW WELLK WELL REPLACEMENT—Er--DESTRUCTION ❑ ` PUMP INSTALLATION SYSTgM�EPAIR ❑ OTPER ❑ DISTANCE TO NEAREST. SEPTIC TANK SEWER LINES 0 DISPOSAL FLD /Q PROP. LINE (} J FOU11NDATION AGRICULTURE WELL OTHER WELLY-4.8 f^ PITS/SUMPS �_C Alc *' INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS �4 ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ,V Domestic/PrivateGravel Pack' ❑ Tracy Type of Casing -_',767C-7J, Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal c5d Type of Grout /?// ❑ Irrigation —gpprox. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type'of Pump H.P. State Work Done (A ` Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION (No septic system permitted if public sewer is j�. vailable within 200 feet.) Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms , Character of soil to a depth ofr3 feet: Water table depth SEPTIC TANK ❑ T;e/Mfg Capacity No. Compartments PKG. TREATMENT PLT.❑ II Method of Disposal Distance to nearest: Well Foundation Property Line ` Y LEACHING LINE—— "❑ No. & Length of lines Total length/size FILTER BED ❑ piistance_to nearest: Well Foundation Property Line SEEPAGE PITSy "❑ Depth Size Number SUMPS -❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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, and d 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 perrnit is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California."Contractors hiring or sub-contracting signature certif-res 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." The applican call for all r �aus� required ins ectior,s. Complete drawing on side. Signed �l�t.� Title: l > o--� _ Date: �. FOR DEPARTMENT USE ONLY Application Accepted by ' i 'Date } Arda Pit or Grout Inspection by ,(� - = r'. •-�, ~• �., '• � � a'•:- r � to Final Inspection by f I t p A 'Tonal Comments: 4 ® ' . tk 466 8781 _ ❑ Lodi 3 3621 ❑ Manteca 823-7104 ❑ facy 04IT/ 7 A !cant.-,Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box , Stk., CA 9x201 ,E FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT'-NO. INFO .CASH ;� ,REV.1el831ff gg L-4-13� N10 _7�-2- g pub-'---