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6. APPLICATION FOR PERMIT SAN lOAQ1Li% LOCA, HEALTH DiSTRICT 117 1601 E. HAZELTON AVE STOCKTON CA 7,T, 5!6V. ERMIT NO. V�3) Telephone (209�'466-6781 �,;, I 11.111 11 11 DATE ISSUED PERMIT EXPIRES I YEAR FROM DATE I . (Complete in Triplicate) _t Application is hereby made to the San Joaquin Local Health District for a permit to construct an /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 Regulat s of the San Jo qui I n Lo al Health District. Job AddressSubdivision Name 60 Owner's Name Address,/3 I V Phone y�/Z _ Contractor's Nam License No. /(o -13 7 ? Phone 6. TYPE OF WELL/PUMP WORK, NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION PUMP INSTALLATION F_.1 SYSTEM REPAIR OTHER L_j DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE j 60 FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS i. INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 0 industrial ElOpen Bottom 0 Manteca Dia. of Well Excavation ❑'-Domestic/Private EJ Gravel Pack 0 Tracy Dia. of Well Casing 17 Public F-1Other 0 Delta Type of Casing F—, Irrigation Approx. E]Eastern Specifications ❑ Cathodic Protection Depth Depth of Grout Seal 60 ❑Geophysical Type of Grout ❑OtherSurface Seal Installed by Repair Work Done d" Type of Pump H.P. State Work Done,011W h.. Well Destruction El Well Diameter Sealing Material (top 50') 'Ji Depth Filler Material (Below SO') TYPE OF SEPTIC WORK: NEW INSTALLATION FI REPAIR/ADDITION 0 (No septic tank or seepage pit permitted if public sewer is available within 200 feet.) Installation will serve: Residence Commercial Other Number of living units: Number of bedrooms Lot size Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK Ej Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. E] Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM o Distance to nearest: Well Foundation Property Line DESTRUCTION LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED E] Distance to nearest: Well Foundation — Property Line 60 SEEPAGE PITS E] Depth — Size Number SUMPS D Distance to nearest: Well Foundation Property Line I DISPOSAL PONDS El 6.. 1 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. 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&compensation laws of California." LT 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 compensation laws of California." The applicaections. CompletezVrawing on reverse side. Signed Xr�a�� )ILTitle: 11_k� Date: Application Accepted by FOR a '6r_.5t1k 466-6781 Additional Comments: --Are Ej Lodi 369-3621 Pit or Grout Inspection by Date Ej Manteca 823-7104 L Final Inspection byf�* 7- Date [] Tracy 835-6385 Applicant - Return all copies to: 'Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 LFEE I BASE AMOUNT DUE AMOUNT REMITTEDPERMIT�NO. INFO 13 _�7 3 �3 3 LEH 13-24 REV. 10182 10182 500 14-26