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dW 3 APPLICATION FOR PERMIT 4 .r SAN JOAQUIN LOCAL HEALTH DISTRICT 1 1601 E. HAZELTON AVE., STOCKTON, CA Telephone {209} 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is fieieby 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 �f City Lot Size PM f [.' ��`z Address r� Phone Owner's Name �`aw Contractor /t'L///J/� /�� t Address �r_1244,") License fro. �[�Phone TYPE OF WELL/PUMP: NEW WELLX WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATIO SYSTEM REPAIR ❑ OTHER ❑ i DISTANCE TO NEAREST: SEPTIC TANK,' SEWER LINES '�� DISPOSAL FLD.— PROP. LINE FOUNDATION' AGRICULTURE WELL f OTHER WELL- ;$e PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS I/ ❑ industrial ❑ Open Bottom ❑ Manteca Dia- of Well Excavation +Dia: of Well Casing Domestic/Private Gravel Pack El Tracy Type of Casing Specifications i f'7 Yublic �her i ❑ Delta Depth of Grout Seal Type of GroutAL I I Irrigation Approx. Depth I 1 Eastern 5 rface Seal Installed by �(f Repair Work Done ❑ Type of Pum l Re p yp p _.._-� H.P. / '�-� State Work Done_ Well Destruction © Well Diameter Sealing Material (top 501 Depth '.t Filler Material (Below 50') TYPE OF SEPTIC,WORK: NEW INSTALLATION I] REPAIR/ADDITION f I DESTRUCTION II- (No septic system permitted it public sewer is .. d , available within 200 feet.) Installation will serve: Residence— Commercial_ Other �* - Number of living units: Number of bedrooms ;. . , �Y Character of soil to a depth of 3 feet: ;Water table depth SEPTIC TANK ❑ Type/Mfg Cepacity No. Compartments PKG. TREATMENT PLT..0 A - ,.Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size s FILTER BED ❑ Distance to nearest: Well Foundation ---Property Line. SEEPAGE PITS 11 Depth Size _ Number s SUMPS D Distance to nearest: Well Foundation Property Line If DISPOSAL PONDS' ❑ y + _ I hereby certify that I have prepared this application and that the work will be done in accordance with SanJoaquin county ordinances,state laws, and rules and regulations of the San Joaquin Local Health DRtrict. i 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, 1 shall not -` employ any person in such manner as to become subject to workman's compensation-19w—sof 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,1 shall employ persons subject to workman's compensa- tion laws of California," The applicant c re ired Complete drawing on revers s779___ -' r Signed X tfe: y Date: [ ` FOR DEPARTMENT USE ONL - Accepted by 41 DateAre. t Pi7orG out I ctiontF) T Date�f �inal Inspection by Data Additional Comments: ❑ Stk 466-6781 ❑ Lodi -3&21 j ❑ Marfteca-623=7104 s p Tracy 835-6385 Applicant - Return all copies to: Environmental health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2409, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT.REMITTED CK A&S� __.'^^R�CEIUED BY DATE PERMIT'NO. ♦.EH1 -241REV.iinal EH 14-26