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APPLICATION FOR PERMI-lam SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Womplete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to ronstnrct and/or install the work herein described. This application is made in compliance with Sari Joaquin County Ordinance No. 549 for sewage or No 1862 for welUpurnp and the Rules and Regulations of the Sall Joaquin Local Health District. f Job Address _! r �/h- r � City_ -�c!y Lot Size PM Owner's Name /+✓�� (- �� {/uC Address X51-! _- iTk ��+Ct.. ��r3i �11,J��)i.��Phone ___ Contractor �( Nt �Ld/�+Zd:J Addess- _rC_rCl.2 ':� �57 .�_license do. Phone TYPE OF WELLIPUMP: NEW WELL I I WELL REPLACEMENT f 1 DESTRUCTION I 1 PUMP INSTALLATION I 1 SYSTEM REPAIR f I OTHER X/71i//r/�''+'v(r (,ae2e. - DISTANCE TO NEAREST: SEPTIC TANK ^'1SU SEWER LINES `-, DISPOSAL FLD.__=_ PROP. LINE 75 FOUNDATION �� r AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 1 Industrial IJ Open Bottom C-I Manteca Dia. of Well Excavation __--/Q" Dia. of Well Casing[ I Domestic/Private IA Gravel Pack I Tracy Type of Casing 'k:r`ff-dL�-,�-��•_f�t_� _ Specifications Cr rr6Y //sem=.v.zv, {'I Public f 7 Other Della Depth of Grout Seal . -"'�S ____ Type of Grout - I I Irrigation "'`rQ'Approx. Depth I I Eastern Srtrfacu Soul Installed b O>r7%�•c.fur _ �� - 1 Repair Work Done i 1 Type of Pump _ H.P. __ _ State Work Done ell Destruction {-I Well Diameter -_ � Sealing Material (top 50') ____L7wt f ,3'tL,r,;aC�ry V(. `r_ Depthizrl � �� FiHer•-�Ra#acial-l-�4ew SA') f7_(vS /j->r-'__cci% Cr.S n(f,,4.`c;a�,/c," tom- I,& 1"4e,'; TYPE OF SEPTIC WORK: NEW INS7ALLAIION I I HFPAIRrADDITION I I DESTRUCTION i I INo septic system permitted it public sewer is available within 200 feet.) Installation will serve: Residence ____ Com ercial ... Other Number of living units: Number of bedr ins Character of soil to a depth of 3 feet: _ —_ _._ _--Water table depth SEPTIC TANK U Type/Mfg pacify_______ No. Compartments PKG. TREATMENT PLT. ( ) Method of Disposal Distance to nearest: Well - Foundation ._ ._ Property Line L EACHING LINE I I No & Length of lines Total length/size _ FILTER BED [ I Distance to nearest: ell _ undation _-_ Property Line SEEPAGE PITS I I Depth Size _—. _� Number _ SUMPS L I Distance t nearest: Well ..__- Fowtdatio ___ Properly Line DISPOSAL PONDS I l 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. f 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 cornpensa tion laws of California." The applicant must call for all required in ctions. Complete drawing on reverse side. Signed X. j .�t_ r r I.� ..I� yJ. -- --- - Title: 1_ ti 1_ �a '��! i �:< r Date: ZX ' + r /FOR DEPARTMENT USE ONLY Application Accepted by -- — Date Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: — I ) Sik 466-6781 L7 Lodi 369-3621 [ 1 Manteca 823-7104 L.] Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOVNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT No. INFO CASH � EH 13.24(REV.I/N 5) �� g �t.J �`•3. vO�v EH 14.26