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APPLICATION FOR PERMIT i SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA } Telephone (209) 466-6781 1 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/of install the work herein described. This application is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for welllpump and the Rules and Regulations of the San Joaquin Local Health District. Z 14 C'city of size _ _ Job Address � - PM Owner's Name _�1 C_� 10�„n�L Address ngaT� �`� - Phone 91-7 Contractor �• �`UGG Address �dLicense No.._? t � Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 11 DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE _ FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS I INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial © Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing 11 Domestic/Private IDGravel Pack LJTracy Type of Casing Specifications F1 Public Cl Other H Delta Depth of Grout Seal Type of Grout I i Irrigation _Approx. Depth l 1 Eastern Surface Seal Installed by - Repair Work Done ❑ Type of Pump H,F?.,_ -State Work Done—• -- 1 Well Destruction 71Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I.1 REPAIR/ADDITION DESTRUCTION I I (No septic system permitted it public sewer is I . 1'` .._ '_ available within 200 feet.) Iinstallation will serve: Residence Commercial_ Other Number of living units: Number of bedrooms i Character of soil to a depth of 3 feet: 924,t%. Water table depth 7A I SEPTIC TANK © Type/Mfg Capacity.-- No. Compartments PKG. TREATMENT PLT. ❑ �` .. Method of Disposal Distance to nearest: Well Foundation Property Line t LEACHING LINE ❑ No. & Length of Eines C,2 15;L0 Total length/size FILTER BED ❑ Distance to nearest: Well_g57_ Foundation 7eJ-�Property Line 43! '' SEEPAGE PITS I 1 Depth Size Number ' SUMPS ' ❑ Distance to nearest: Well Foundation Property Line i DISPOSAL PONDS ❑ I hereby certify that I have prepared this application anb 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. ` 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,perfofmance of-fhe work for which this permit is issued,,l.shall employ persons subject to workman's compensa- tion laws of California." ; f M The applicant must call for all regg firJZKnstions. Complete dravLing;on'reverse side. `Signed X C.[ r ��. — Title: _1 g:2e&.2ftDate: Ze s, %t , DEPARTMENT USE ONLY Application Accepted by Data Area ` Pit or Grout inspection by Date Final Inspection by/o/41--tDate i . 1 Additional Comments: ❑ Stk 466-6781 L7 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 2005, Stk., CA 95201 l FEE AMOUNT DUE - •-•AMOUNT REMITTED CK- RECEIVED BY, � - -DATE PERM1T•NO." - -'•'� INFO - CASH = T ~ SEH 13-241REV �'"" is //�� W 14 y