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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T 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. Job Address 1�`a0 �'��Cro�u City Lot Size �t7 �r PM ]� ' Y -- 03 �L Owner's Name r 2�k r� t r'- Address Phone Contractor Dods d' OQ/ I'VSA4ddress 1614+ G//1 AjFj ,L4ce-dR4 License No fg Phone 5`2 O 71 TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT X DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER Cl DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES loot DISPOSAL FLD150'.,_ PROP. LINE J O1 i FOUNDATION 106 • AGRICULTURE WELL OTHER WELL3-Q(—)' PITS/SUMPS 4 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 ❑ Tracy Type of Casing - Specifications ❑ Public ❑l Other C] Delta Depth of Grout Seal top 1 _ Type of,Grout 71 Irrigation ,4 �Approx. Depth ❑ Eastern Surface Seal Installed by C n Repair Work Done ❑ Type of Pump Std� H.P. _ J� State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 - Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ Mo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence— Commercial_ Other ' Number of living units: Number of bedrooms .. Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 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. 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 applicant must II for all squired in ctions. Complete drawing on reve�de. Signed _ Title: G Date: FOR DEPARTMENT USE ONLY Applicati n Accepted by �, Date 7� _ Area ' 2- Pit or rot Inspection by `- Dat - E�Final Inspection by Date Additional Comments: 1'U' s d f~ P ❑ Stk 466-6761 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6305- Return all copies to: Environmental Heaith Permit/Services1601 Haz ton Ave., P.O. Box 2009, Stk., CA 95201 6 � V sT;� W 6�2-� �` FEE AMOUNT DUE AMOUNT REMITTED C K RECEIVED BY DATE PERMITNO. INFO �7 + EH 13-24(REV.1/85) EH 1428 1�r -706 1 jig+S /