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APPLICATION FOR PERMIT �{ SAN JOAQUIN LOCAL HEALTH DISTRICT :i )0 � 1601 E. HAZELTON AVE., STOCKTON, CA `� k4 ?�/ I Telephone 1209? 466-67$1 \ EAR FROM DATE ISSUED Cos I [ PERMIT EXPIRES 1 Y {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/pu and the Rules and Regulations of the San Joaquin Local Health District. : IPM City of Size 2 g ,� Job Address } dress" ass ` Phone 0 Owner's Name - _ .w ..�.... -_ ...�....�.... ._..,,�, .—:5.....,�g r� ' "t ® / /" License NOV-5K Phone! S /� Contractor ddress t TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ w PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ 1;rOTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP, LINE FOUNDATION AGRICULTURE WELL OTHER WELL 'PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 1, ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation` Dia. of Well Casing J I ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing ' Specifications ° d t 15Publc ❑ Other ❑ Delta Depth of Grout Seal t Type of Grout r 11 Irrigation il-Approx, Depth l I Eastern 'Surface Sedl installed by - i HIP. t State'Work Done Repair Work Done ❑ Type of Pump r �. # t _ Welt Destruction ❑ Well Diameter Sealing Material (top 50') ' ' �P ! Filler Material (Below 50'1 Depth (� U1 TYPE OF SEPTIC WORK; NEW INSTALLATION EPAIR/ADDITION l I DESTRUCTION l I (No septic system permitted if public sewer is available within 200 feet.) y F' Installation will serve: Residence_ Commercial —Other Number of living units: Number of bedrooms :- I mo.X f��l ! Character of soil to a depth of 3 feet: 4k Water table depth Capacity No. Compartments ;. SEPTIC TANK D Type/Mfg jN�V�PKG. TREATMENT PLT. ❑ _ Method of Dispose i t ll.", �Distance to nearest: Well — Foundation Property Line ot LEACHING LINE �,� ❑I o &,Length of lines } Tot length/size FILTER:BED ❑` Distance to`nearest: We11' `;Foundationy� Property Line . SEEPAGE PITS 1 I ,Depth Size Number SUMPS ❑ ,Distance to nearest: WeII�D Foundation -- Property Line o I 7 DISPOSAL PONDS F =❑ P } 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 L rules and regulations of-the,$an Joaquin Local Health District. + 4 Home owner or licensed agents signature certifies the following: "I certify that in the performance of the work for which this permit issued, f shall not employlany person in such,manner as to become subject to workman's compensation laws of California." Contractor's(tiring 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 st call for all uired in ctions. Complete drawing on reverse side: SignedtX Title: Date: ; f. FOR DEPARTMENT USE.ONLY II I Application Accepted by Date Area r++, v'of '.;W W T�l t� Dat� J `�. Pit or Grout Inspection by � Date:Z� Final inspection by V ooAdditional Comment ; r ❑ 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, SW., CA 95201 FEE �e INFO AMOUNT DUE AMOUNT REMITTED CASA RECEIVED BY DATE PERMIT NO. M + EH 13-241 REV.t H 57 II