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t APPLICATION FOR PERMIT _ SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. �HAZ�E�r,ONAV�E., STOCKTON, CA Telephone (209) 466-6781 ns PERMIT EXPIRES I YEAR FROM DATE ISSUED G.�, (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.d"esctr etii `1=P"iis application is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules at;' ns ns of the San Joaquin I Local Health District. P 952 3 Job Address I Q��-- - � City/ ize PM -j- r Owner's Name Address / a f7 • Phone ContractIrLC-J�. ftess PQ 1911X-192L7 License Nol b 2- ,hone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ UDE TRUCTION; ❑ 1 PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ { DISTANCE TO NEAREST: SEPTIC TANK w -SEWER LINES DISPOSAL FLD. PROP. 'LINE FOUNDATION _ n ,AGRIEULTURE•WELI -�4yOTHER WELL PITS/SUMPS _ 11 INTENDED USE TYPE OF WELL PROBLEM'AREA CONSTRUCTION-SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Weli Excavation Dia. of Well Casing c ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of CasingPKC. Specifications ❑ Public ❑ Other ❑ Delta' ,_.r........Depth_of.Grout#Seal..t Type of Grout y _ . ,.,._. I I Irrigation --Approx. Depth 11 Eastern Surface Seal Installed.by,��"" Repair Work Done W Type of Pump H.P. f ��- State Work Done _ -Ce, Well Destruction ❑ Well Diameter Sealing Material Itop 501 , •�` ~j Depth Filler Material Ieelow 50'1 r TYPE OF SEPTIC WORK: NEW INSTALLATION I:1 REPAIR/ADDITION [ I DESTRUCTION I I (No septic system permitted it public sewer is v l available within 200 feet.) ag _ Installation will serve:., Residence_ Commercial_ Other t Number of living-units:---Number-of-bedrooms------------ Character iving units:_...._- --.._Number-of-bedrooms-- -* --•�--- T ------•---• �•-•.-----�----- -• -r.�.,,,�. Character of soil to a depth of 3 feet: ;. i —��+� s • - Water table depth E SEPTIC TANK ❑ Type/Mfg t 7!ni XZ' Capac ty No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Lime LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line I SEEPAGE PITS 11 Depth Size Number SUMPS L-i Distance to nearest: Well Foundation Property Line t DISPOSAL PONDS ❑ J 9 I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state taws, 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 son in ch manner as t b o bject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature certifies t following:' ertify tha r nee of the work for which this permit is issued, I shall employ parsons subject to workman's compensa- tion la of California + The a licant u for a q C plate drawing on re I e. q Signed Title: 4r - Date: 4-- / / 0 a R DEPARTMENT USE ONLY Application Accepted by Date J Area Pit or Grout Inspection by Date Final Inspection byate �? Additional Comments: t ❑ Stk 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 RUE AMOUNT REMITTER CK it CASH RECEIVED BY DATE PERMIT'No. + EH 13.24(REV.r/a 51 „b EH 10-28