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� � l APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT EEEEEE 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES YYEAR FROM DATE ISSUED (Complete in Triplicate) and/or Application is hereby made to the San Joaquin Local Health District for a permit to construct the work herein described. This application is and 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 F Local Health District. i C PM I Job Address City Lot Size � Phone `�``IV Owner's Name Address J E License WELL Phone Contractor Address TYPE OF WELL/PUMP: NEW WELL n WELL REPLACEMENT El DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR 1:1OTHER ❑ f DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP.•LINE FOUNDATION AGRICULTURE WELL OTHER WELL— INTENDED [ INTENDED USE': TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS !!� Dia. of Well Casin El Industrial ❑'Open Bottom El Manteca Dia, of Well Excavation g Domestic/Private ❑ Gravel Pack CJ C3 Tracy Type of Casing Specifications FI Public n Other n Delta Depth of Grout Seal Type of Grout------ I rout_-- ---I I Irrigation _.-Approx. Depth I I Eastern Surface Seal installed by - 4 j Work I Repair Work Done ❑ Type of Pump H.P. State k Done— ) Weil Destruction ❑ Well Diameter Sealing Material (top 501 i Depth Filler Material (Below 501 -- TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIRIADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is ` I available within 2DO feet.) installation will serve: ej e: Residence✓Commercial— Other Number of living units: L Number of b rooms 3 l_�t J, vI� Character of soil to a depth of 3 feet: _ —Water table depth_/_66 SEPTIC TANK CY Type/Mfg -14"Xt`_ Capacity f1O No. Compartments Z PKG. TREATMENT PLT. ❑ ;, Method of Disposal �} ' Distance to nearest:' Well 7� Foundation �*� � Property Line �� t LEACHING LINE L'V/No. & Length of lines { i Lie Total length/size � FILTER BED ❑ Distance to nearest: Well.+l qp l Foundation t Property Line / r 1 1 I SEEPAGE PITSI',,-Depth _Size t t: Number SUMPS F1 Distance to nearest: Well t�-2 Foundation Lp©r _ Property Line DISPOSAL PONDS ❑ i 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. `•, I ! 1 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 l employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub contracting signatu�e 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 applic t mu t call f r all requi do ctions. Complet,drawing on reverse side. I Signed X `Title: Date: '2--9-23 P62 FOR DEPARTMENT USE ONLY �j" Application Accepted by Date / (0Area it or Grout Inspection b211 y Date4 =- Final Inspection by ate Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ MantecaB23 7104 " C7 Tracy 835.6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 rl FEE AMOUNT DUE AMOUNT REMITTED ASH RECEIVED BY DATE PERMIT'NO. INFO r� � �/(f a,EH 13-24 iREV.t i 1 - TO �� Tj / D 2 x 5l ' (J EH 14-26 1 '�