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Y • APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE TON 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.186.2 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address Ci =' Lot Size rp a=,e�M Owner's!Jame Address aohone ` , L' Contracto �} Address License No Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP.,LINE' FOUNDATION AGRICULTURE WELL OTHER WELL. PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS— El Industrial PECIFICATIONSElIndustrial EJOpen Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications . kV ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout + Q ❑ Irrigation ---Approx. Depths ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump > H.P. State Work Done `f i Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Bel ') �1 TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR! DITION DESTRUCTION ❑ (No septic system permitted if public:sewer is \\\I a ilable within 200 f t.) Installation will serve: Residence_ Commercial Other Number of living units: —6)- Number of bedrooms Character of soil to a depth of 3 feet: Water table depth ,x„ SEPTIC TANK ❑ Type/Mfg CapacityNo. Compartments ` 1 PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line � 4 LEACHING LINE No. & Length of lines f•_ U O Total length/size' WO FILTER BED ❑ Distance to nearest: 1+Velfti Foundation Property Line 3 ` * r SEEPAGE PITS Depth 2S ze '`. _ Number of SUMPS ❑ Distance to nearest: Well Foundation Property+ine- i 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. s 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."Contractoes 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 em6l6y persons subject to workman's compensa- tion laws of California." The applicant mu call for all requir d inspections. Complete drawing on reverse side. i ' Signed .-�� Title: � Date: FOR DEPARTMENT USE ONLY ) Application Accepted by Date 7�2 — (I Area . Pit or Grout Inspection by Dale Final Inspection by Date Additional Comments: "'` .r' :; ❑ Stk 456=6781• ❑ Lodi 369-3621 O'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 95201FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. 4EN 3-24(REY.ea i5) EN14-2g