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. �tT -Ole, APPLICATION FOR PERMIT `' SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON 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. Joh Address City f Lot Size PM - f Owner's Name 11lr �9 +// /1/�/ ylWess /--'7 /� Phone 70 Contractor `+� Address v� ' License No. Pho e , _ TYPE OF WELL/PUMP: NEW WELL C1WELL REPLACEMENT ❑ DESTRUCTION C] 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 OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS L4 - ❑ Industrial r ❑ Open Bottom ❑ Manteca Dia. of Well Excavation -Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications f'l Public ❑ Other R Delta Depth of Grout Seal Type of Grout _ i I Irrigation ! Approx. Depth I 1 Eastern Surface Seal Installed by Repair Work Done ❑. Type of Pump H.P. State Work Done _ �- Well Destruction O Well Diameter Sealing Material-ltop-501 Depth Filler Material {Below 50') -- TYPE OF SEPTIC WORK: NEW INSTALLATION tr REPAIR/ DDITION I I DESTRUCTION I I (No septic system permitted if public sewer is available within 204 feet.) Installation will serve: Residence— Commercial_ Other 7 � � Number of living units: Number of bedroorns Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg / Capacity No. Compartments PKG. TREATMEN�PLT'. ❑ - - ��y„rp Method of Disposal Distance to nearest: Well - Foundation Property Line LEACHING LINE No. & Length of lines Tgtal length/size � FILTER BED Distance to nearest: Well //19P .... Foundation leProperty Line SEEPAGE',,PITS Depth Size Number Well SUMPS L] Distance to nearest: Wel =.! _ oundation ;r 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 Di$trict. 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 applican mu c I all required inspections. Complete drawing on reverse side. %A,a Signed- ' - Title: Date 1"i.. _ � s/1FOR ARTMENT USE ONLY s Application Accepted by Date t r Area I Pit or Grout inspection by Date Final Inspec ion by Date f' / � Additional Comments: 9� / Q 1 � " �1�� ❑ Stk 466-6781 - ❑ Lodi 369-3621. E],Mantac 823-7104 ❑ Tracy 835-6385 y U. Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 '41'uly^1 w / f FEE AMOUNT DUE AMOUNT REMITTED C K RECEIVED BY DATE PERMIT'NO. INFO _.. . It-_241REV.s/145)Ze __ � .-10:()0 `70- ov_