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'WO'' APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (2091 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED IComplete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein desc��rii ry,r,{ TfJjvJp�i6�tion is made m i compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 far well/purnp and the R�l V14RNt t1 AAlri n Joaquin Local Health District, Q�RM}�IS Job Address — r City Lot Size PM t t ' Owner's Name � Address • 3 _�6�L� Phone Contractor Jr —Address k4z License No.6W:7/4/ Phone ' TYPE OF WELLIPUMP: NEW WELL Cl WELL REPLACE ENT D DESTRUCTION Ll PUMP INSTALLATION SYSTEM REPAIR OTHER LI DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES ._ D SPOSAL FLD.__ PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS LJ Industrial L; Open Bottom C1 Manteca Dia. of Well Excavation _ Dia. of Well Casing --_.- 'V, Domestic/Private [l Gravel Pack I Tracy Type of Casing Specifications I'1 Public f1 Other i1 Delta Depth of Grout Seal Type of Grout I i Irrigation __.Approx. Dejqji I 1 Eastern Surface Seal Installed by Repair Work Done (A Type of Pump H.P. State Work Done Well Destruction f_l Weli Diameter Sealing Material (top 50') � Depth �S7 � - Filler Material (Below 501 —_ TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permilted if public sewer is available within 200 feet.) Installation will serve: Residence . Commercial __ Other j Number of living units: -. Number of bedrooms 4, Character of sail to a depth of 3 feet: Water table depth SEPTIC TANK 1-1 Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT, Li Method of Disposal Distance to nearest: Well Foundation Property Line t �l LEACHING LINE L1 No. fir Length of lines Total length/size FILTER BED L) Distance to nearest: Well_ Foundation Property Line SEEPAGE PITS v [ I Depth Size _ Number SUMPS 1 Distance to nearest Weil Foundation Property Line DISPOSAL PONDS I t c� I hereby certify that`l have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, andJ 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's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the following: "I Yy that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compansa. tion laws of California." The applicant must c I raquir d ctions. Complete drawing on reverse side. Signed X Title: . Data: FOR DEPARTMENT USE ONLY Application Accepted by Date Area 7 Pit or Grout inspection Data Final Inspection by Date Additional Comments: Ll Stk 466.6781 O Lodi 369.3621 D Manteca 823-7104 D Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASHCx RECEIVED BY DATE PERMIT N0. . EH 13-24 iREV.r i w si34 y/ ff 7-2S7 EH 14-2e ��p��