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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL 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,complianC titiith San:Jaatjuifi GountyrOrdrnance:tVo'b49 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Healthx Dlstnct. .,' XVA� (a/ v G� { Job Address City Lot Size ae, PM Iu5SE Owner's Name r'.fLe iUt.O Clf�°.`1vSIddress __!_l� J� UC �, �ll Phone Contractor ddress L3525' ansa No. ltIqO,& Phone TYPE OF WELL/PUMP: V NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER/1i1P. SEWER LINES DISPOSAL FLO. n6ne_ PROP. LINE ---: FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ra ❑ Industrial ❑ Open Bottom L1 Manteca Dia. of Well Excavation PJ 2 v Dia. of Well Casing 6 ' ❑ Domestic/Private Gravel Pack X Tracy Type of Casing Specifications t f"1 Public (=7 Other C) Delta Depth of Grout Seal Type of Grout 'LL1Xe�'.�PG,!J�i 1, // f I" t X Irrigation (.L>sf�_Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Wor W41 Well Destruction ❑ Well Diameter Sealing Material Itop 50'1Ati64 ?4tGNNy � } Depth Filler Material (Below 60') (/ vj TYPE OF SEPTIC WORK: NEW INSTALLATION I.] —REPAIR/ADDITION i I DESTRUCTION l I Wo 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 I SEEPAGE PITS l I Depth Size Number { SUMPS ❑ Distance to nearest: Well Foundation Property Line r - DISPOSAL PONDS'-- -❑—' ._.. hereby certify that t 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: 1 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-Cat'ornia." The applican ust call for all requi inspections. Co plate drawing reverse si 19jO Signed TitlDate FOR DEP TMENT USE ONLY Application Accepted by / '"f Date Area � 1 Pit or Grout Inspection by Data Final Inspection by Date�a v-t'f�' I Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 Cf Manteca 82,0104 ❑ Tracy 835-6365 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 i FEE AMOUNT DUE AMOUNT REMITTED CK"INRECEIVED BY DATE PERMIT NO. INFO ♦.EH13-24 MEV,t i n 5) EH 14-26 / �St i `�'� /( p