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µ APPLICATION FOR PERMIT a I SAN JOAQUIN LOCAL HEALTH DISTRICT + 1601 E. HAZELTON 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. Job Address y City Lot Size 1;7J SZPM Owner's Name - Address S' Z-47 e2\ _ Phone — License No:" "" •" Phone -07 Contractor's Name _ T� TYPE OF WELL/PUMP: NEW WELL 71 WELL REPLACEMENT LJ DESTRUCTION ❑ k ,_-'^ -` •PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE'$TO NEAREST:-SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. U ; '-FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS MT INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS' ,. + - ❑ Industrial ElOpen Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Type' -�"y❑'Domestic/Privati3 '❑ Gravel Pack T_k ❑ Tracy YP of Casing Specifications ❑ Publics ❑ Other ❑ Delta Depth of Grout Seal Type of Grout + ❑ Irrigation I---Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction i El Wel! Diameter Sealing Material (top 501 Depth ! Filler Material (Below 501 TYPE"OF-SEPTIC',WORK7";NEW-INSTAL"LAT1ON- REPAIR'/ADDITION'❑'DESTRUCTION ❑-(N6 septic system permitted if'puolic sewer is- available within 200 feet.) �Z Installation will e: Residence a Commercial_ Other (� Number of livirig�units:_- /_ _Number of bedrooms Character of soil,to a depth of'3 feet: 6 e— Water table depth {� SEPTIC TANK t Type/Mfg _ �� 466! Capacity—J-2 — No. Compartments PKG. TREATMENT PLT Method of Disposal Distance to nearest: Well Foundation Property Line t LEACHING LINE No. & Lengthtof lines Total length/size Z FILTER BED ❑ Distance to neatest: Well�._ Foundation_ l� ° Property Line � � k SEEPAGE PITS Depth I 2X Size 1 r/ Number I SUMPS ❑ Distance to nearest: Well P" Foundation Property Line DISPOSAL PONDS, - I hereby certify that I have prSpared this application and that the wok 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. tl 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 iri 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 applican call for all required inspect C mplete drawing on givers p/ p Signed f Title: Datb: p a OR DEPARTMENT USE ONLY Application Accepted by PQQC&IA Date —8 Area --�" n Date G f— Pit or Grout Inspection by =`f �a- Date Final Inspection by Q L r Additional Comments: 1 ❑ Stk 466-6781 ❑ Lodi '369421 ❑,Manteca 823-7104 ❑ Tracy 835-6385 r Applicant- Return all copies to: Environmental-Wealth Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 + FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT`NO. INFO + EH 13.24 IREV.1018831 ©.a �� / -Tli-71 EH 1126