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~ APPLICATION FOR PERMIT .rw SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 7 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 whh San Joaquin County Ordinance No.549 for sewage or No. 1852 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. D 6 Job Address /33�2r1,�� / //L City 375 ONLot Size PM Owner's Name • �� ^ DO A10, Address , :�q106-S-4 -4—bPhone Contractor's Name S License No. `� —� --/ Phone GG TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK - SEWER LINES DISPOSAL FLD._— PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OFWELL — PR.OBLEM AREA l''CONSTRUCL_ SPECIFICATIONS FI Industrial ❑ Open Both ❑ Manteca ia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications L111 [[ WPublic ❑ Other Delta Depth of Grout Seal Type of Grout 4 ❑ Irrigation --Approx. Depth ❑ Eastern-- Surface Seal Installed by r Repair Work Done ❑ Type of Pump I H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION jP1 DESTRUCTION ❑ (No septic system permitted if public sewer is 01) rL� available within 200 feet.) Installation will serve: Re"ffce= .Commercial Other Number of Irving units: umber of bedrooms r Character of soil to a.deip4 of 30eet: /a d7N8JL Water table depth zoo 7p SEPTIC TANK ❑ Type/Mfg k Capacity No. Compartments: A PKG. TREATMENT PLT. ❑ Method of Disposal �• Distance to nearest: Well Foundation Property Line �... O LEACHING UNE f�Nb. & Length of lines �� YO Total length/size N FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS Depth a s in ya Number SUMPS ❑ Distance to nearest: Well Foundation !O •10• Property Line DISPOSAL PONDS ❑ 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 compensatiop laws of California."Contractor's hiring or subcontracting signature certifies the followin : "I certify that in the performance of the work for which this permit is issued, 1 shall employ persons subject to workman's compensa- tion laws of Cal' m . The applican u ca f all r it d ins ction5 Complete drawing on reverse -sidle/. Signed Title: �l/ � Date: 1`�� -;;Z OR DEPARTMENT USE ONLY o, A Ii0stion Accepted by Crt ,,, � . C ` y..�q��[� Ayy ,—f .-• Date ,,,(��— 1�—�/S�(�/Area d �p� ��r Pit r Grout Inspection by e2L AA ate�7 r"e Final Inspection by 0 rl,, a+++.^o` Date g Additional Comments: ❑ Stk 4668781 ❑ Lodi 369-3621 ❑ Manteca 823-7106 ❑ Tracy 836483M Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE NFO CAAMOUNT DUE AMOUNT REMITTED CK SH RECEIVED BY DATE PERmrrwo. + EH 1314 IREV.10/11 EH 1426 ! 1� A. S 10 of