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APPLICATION FOR PERMIT thereins, SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZETON AVE., STOCKTON, CA Telephone (209) 466-6781PERMIT 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 woapplication 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 Distrriicctt. _ Job Address _,T /y G ��,�.QI✓ City Lot Size ;7-0?!;!1Pill Owner's Name ~Address eI9/07/-s Phpne Contractor Address License No, Phone 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 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom I] Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications f I Public 1-1 Other f7'Delta Depth of Grout Seal Type of Grout__,. I Irrigation _Approx. Depth I Z Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material Itop 501 Depth-- •—W , Filler Material Melow 50'1 —_ TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION I I DESTRUCTION € I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial____ ther Number of living units: _/_ Number of 5�1bedro ms�� Character of soil to a depth of 3 feet: �N_ / I 1", Water table depth SEPTIC TANK ❑ Type/Mfg ! f' ��N6f Capacity Z _OD No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well d0*1' Foundation Property Line d!:7 70' LEACHING LINE ❑ No. & Length of lines :5? Total length/size 41e FILTER BED ❑ Distance to nearest: Well y21Foundation 240 t5 Property Line SEEPAGE PITS I 1 Depth b SizerQ Number SUMPS Ll Distance to nearest: Well-—0 Foundation —200!)t Property Line DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work will be done in accordance with Sart 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 mW call for all require inspection om a drawing on reverse side. J7 Signed X �1.yeilr. ` Title:' ©G�/V G'� Date: ! O FOR DEPARTMENT USE ONLY Application Accepted by Date Area Pit or Grout Inspection by Date_ Final Inspection by 9 gj, Date Additional Comments: El Stk 466.6781 ❑ 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 2009, Sik., CA 95201 )NFO AMOUNT DUE AMOUNT REMITTED CASH CK RECEIVED BY DATE PERMIT•NO. ♦.EH13-24MEV.i/Kal EH 14-26 'v