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APPLICATION FOR PERMIT it SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA I'I a. Telephone (209) 466-6781 � : . PERMIT EXPIRES 1 YEAR FROM DATE ISSUED k (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 c2sat City Jqr Lot Size ' PM Owner's Name Address _15AA'L Phone Q Contractor Address � License No. t Phone34 X33 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ ` DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS s INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS I ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Oia. of Well Casing 1 ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications 91 11 Public ❑ Other 11 Delta Depth of Grout Seal Type of Grout 1 I I Irrigation ____..Approx. Depth IIEastern Surface Seal Installed by - v Repair Work Done ❑ Type of Pump H.P. State Work Done ' Well Destruction ❑ Weil Diameter Sealing Material (top 501 -Depth Filler Material (Below 501 — TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIR/ADDITION DESTRUCTION E I (No septic system permitted if public sewer is available within 200 fact.) Installation will serve: Rest nce commercial Other l Number of living units Number oftigorooms 3 7 Character of soil to a depth of 3 feet: ` Water table depth V'f SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments {t j=111 PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line 1�4 i LEACHING LINE UI-11b. & Length of lineso �j,�Tot/al length/size FILTER BED L3 Distance to nearest: Well 1020 ! Foundation v__;__._,_ Property Line SEEPAGE PITS U----Depth 2 Size Number SUMPS Cl Distance to nearest: Well Foundation a0 Property Line DISPOSAL PONDS ❑ I hereby certify that I have�pfepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of th,.Sjn Joaquin Local Health D%i trict. Home owner or licensedage 1'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 certifies3he 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.." 8 r R ' L4 t The applicant ust}call f all i uif4d inspections. Complete drawing on reverse side. J / 4 I Signed X "�' itle: 4040 s ' Date. L O'0? Y Y..... c.... .. �'�+ 1 t FOR DEPARTMENT-LISE'ONL-Y r I Application Accepted by�+ i v: r Date Q Area r t �2 � Finallns Pit' Grout Inspection by � ate- � ped tion by Dat r 9 Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 l 0 Mhnteca 8234104- ❑ Tracy 835-6385 Applicant - Return all copies to: Environmentaf-Iidalih•Permit/Services 1601 E. Hazelton Ave., P.O: Box 2009, Stk., CA 95201 I AMOUNT DUE- -•AMOUNT REMITTED -CK �'�}RE�EIVEp BY �TM DATE PERMIT'NO. �.. INFO c �V / +.EH 13.24(REV. /H 51 ' EK 14-28 !h. ilj