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'"W APPLICATION FOR PERMIT 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 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. f` ` s' Job Address ,J r l�f tom- '�� City { Lor Size PM 1 /n y f / q C / Owner's Name, Address � lL L/�Lj ,' 2ce Phone _ Contractr5c/ 1 1��a ` } Address &L�2XC-� �{-, f f1e"Il 7 Z � .L License No.J�o rY phone TYPE OF WELL/PUMP- NEW WELL F1 WELL REPLACEMENT [] DESTRUCTION F] PUMP INSTALLATION Ll SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. _— PROP. LINE ` FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS F} Industrial 1-1 Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of WeU Casing i 1 Domestic/Private ❑ Gravel Pack 1] Tracy Type of Casing Specifications I'1 Public I Other I 1 Delta Depth of Grout Seal _ Type of Grout _ I I Irrrgallon _ Approx. Depth I I Eastern Surface Seat Installed by Repair Work Done ❑ Type of Pump H.P. -_— State Work Done Weil Destruction I l Well Diameter _ Sealing Material (top 50') Depth _ Filler (Bolo_w 50') TYPE OF SEPTIC WORK: NEW INSTALLATION I ] REPAIR ADDITION DESTRUCTION I I (No septic systern permitted if public sewer is available within 200 feet.? �fInstallation will serve: Redence �/ Commercial _ 0 he / Number of living units: Number of Brooms Character of soil to a depth of 3 feet: Water table depth 722 SEPTIC TANK ❑ Type/Mfg �� _ Capacity_ No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal . Distance to nearest: Well _- Foundation Property Line LEACHING LINE NNNo. A Length of lines _ Total length/size---- Fit-TER ength/size _—_FELTER BED Ll Distance to nearest: Well Foundation Property Line SEEPAGE PITS X Depth Size Number _- SUMPS I 1 Distance to nearest: Well _. �-;r Foundation �. Property Line DISPOSAL PONDS LJ 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 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 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 4n t call for all r rred spections. Complete drawing on reverse sid Signed X \ /�G 2-[ _-- �� Title: Date: FOR DEPARTMENT USE ONLY Application Accepted by 4 Date d Area or Grout Inspection by Date �-Final Inspection byate Additional Comments: _ ❑ Silk 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 INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. . EH 3-24 I.nsl H r +f./11