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( APPLICATION FOR PERMIT , r SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is heieby 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. S3 1 _ y —.t, SZ2— l�{� �u T•H+ 2ex Job Address City Lot Size J PM /7 Owner's Name -� �/ ' ddress �-� z _Phone . [_ 7to/ Contractor I ! ddress �`� Gy��- License No. WS/116-Phone TYPE OF WELL/PUMP: r NM WELL WELL REPLACEMENT-0; DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR C, 1 OTHER ❑ I DISTANCE TO NEAREST: SEPTIC TANKEWER LINES ` 'DISPOSAL FLD._ PROP. LINE 4S FOUNDATION AGRICULTURE WELL =n— OTHER WELL PITS/SUMP INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIO "4ndustrial ❑Open Bottom U Manteca Dia. of Well Excavation Dia.i f'Well Casing l Domestic%Private XGravel Pack ❑ Tracy Type of Casing ` Sp6cificatiuns I"1 Public' cI 1 ojher 71 Delta Depth of Grout Seal �� .'Type of Grout 1 1 Irrigation /ptr: Approx. Depth I I1Easastern Surface Seal Installed by A!5,CA415IA_Z N - Repair Work Done L1 Type of Pump H.P. Z� State Work Done . I Well Destruction ❑ Well Diameter Sealing Material Itop 50') Depth Filler Material (Below 50') l TYPE OF SEPTIC WORK: NEW INSTALLATION f l REPAIR/ADDITION I I DESTRUCTION 1 1 (No septic system permitted if public sewer is available within 200 feet_l Installation will serve: Residence_ Commercial_ Other Number of Irving units: Number of bedrooms Character of soil to a depth of 3 feet-. J. Water table depth SEPTIC TANK D Type/Mfg Capacity No. Compartments _ d PKG. TREATMENT PLT. 71 Method of Disposal Distance to nearest: Well Foundation Property Line 1 LFACHING FINE ❑ No. & Length of lines Total length/size T FILTER BED ❑ Distance to nearest: Well Foundation Property Line - SEEPAGE,PITS 1 I Depth -Size Number SUMPS L1 Distance to nearest: Well Foundation Property Line DISPOSAL PONDS Elr 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, and rules and regulations of the San Joaquin Local Health Di§trict- 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." Contractors 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." The applicant u t AI qu' ns. Complote drawing on re sid /r Signed X Title: _D/ Date: l F DEPARTMENT USE ONLY Applicati cepted by Date `! Area I _ Final Inspec Pit or rou spection by Date J� -/, tion by L Date /Z D Additional Comments: ❑ Stk 466-6781 ❑ Lodi 368-3621 ❑ Mant ca -7104 V ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601.E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 INF EE MOUNT DUE AMOUNT REMITTED GAS RECEIVED BY DATE PERMIT-N0. +.EM1}24 IREV.I r n 51 �_f O,�e�V I EH 14-26