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I APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 15 1601 E. HAZEL.TON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRESI]1 YEAR FROM DATE ISSUED (Co gplete 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 forlsewage or No. 1862 for well/pomp and the Rules and Regulations of the San Joaquin Local Health District. �y l Job Address _ C/ ®JJV— City Lot Size PM Owner's'Name Address Phone -71 MIN MaL Contractor � A Phone D 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 l INTENDED USE TYPE OF,WELL PROBLEM AREAL" CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation��/ Dia. of Well Casing [7 Domestic/Private Gravel Pack L1 Tracy Type of Casing_T _ Specifications Public ❑ Other n Delta Depth-of Grout Seal Type of Grout >drrigation _3W-Approx. Depth I I Eastern Surface S88 Installed by Repair Work Done Ll of Pump H.P. / Q State Work Done_ 4 Well Destruction El Well Diameter Sealirilg Material (top 50'i _ Depth Filler Material IBelow 50`) TYPE OF SEPTIC WORK: NEW INSTALLATION i 1 REPAIR/AdDITION I I DESTRUCTION I I INo septic system permitted it public sewer is II available within 200 feet:) Installation will serve: Residence Commercial T Other Number of living units: Number of bedrooms �N Character of soil to a depth of 3 feet: IN. Water table depth SEPTIC TANK ❑ Type/Mfg IM Capacity No. Compartments PKG, TREATMENT PLT. ❑ ' r Method of Disposal Distance to nearest: Well �' Foundation,—.Property Line I� LEACHING LINE Cl No. & Length of lines Total length/size FILTER'BED u ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS l I Depth Size Number SUMPS, Cl Distance to nearest: Well IM Foundation Property Line DISPOSAL PONDS ❑ IN 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 Di1trict. 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." S �� i, } The applicant rTwst• I! for II requvq ctions. Complete drawing on raver Vide. Signed X Title: F — Date:. wo r t FOR DE RTMENT USE ONLY 2 Application Accepted by Date ��J Area Pit or Grout Inspection by _ Date . Final Inspection by i�7iI�1 Date Additional Comments: I� I ! V —Q-Stk- 466-67819-Lodi•...369-3621.—❑-Manteca. .@23- 104—.171-Tracy '835-6385— Applicant 835-6385—Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazalton Ave., P.O, Box 2009, Stk., CA 95201 t 7 S a FEE INFO AMOUNT DUE AMOUNT REMITTED�k GASH RECEIVED BY DATE PERMIT-NO. r a r. +.EH1324 IREV.1/0 51 I� 3 EH 14-29 -F �1