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R f ;f APPLICATION,.FOR PERMIT u SAN JOAQUi",' LOCAL HEALTH DISTRICT 1601 F. HAZELTON AVE., STOCKTON, CA PERMIT N0. C�10 Telephone (209) 466-6781 DATE ISSUED t 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 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 District, Job Address a2 Subdivision Name Owner's Nam i' Address�� r/e�i.s �j� � hone Contractor's Na . `-.License No.. Phone gZ�_ A TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ } DISTANCE TO NEAREST_: SEPTIC TANK SEWER LINES DISPOSAL PLO. PROP. LINE r n FOUNDATION AGRICULTURE WELL. OTHER WELL PITS/SUMPS INTENDED USE TYPE OFNELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Domestic/Private ❑ Gravel Pack E] Tracy Dia. of Well Casing ❑ Public ❑ Other"i ❑ Delta T Irrigation Approx. ❑ Eastern Sppececifications of Casing ❑Cathodic'Protection Depth } Depth of Grout Seal ❑Geophysical � Type of Grout , Other Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50') Q TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ (No septic tank or seepage pit permitted if public sewer is �, �fA��/�I 46 6,Y[l(_ f� �� available within 200 feet.) Installation will serve: Resiaenc _ Commercial t er Number of living units: Number of bedrooms Lot size Character of soil to a depth of 3,feet: Water table depth f w SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments >� PKG. TREATMENT PLT. ❑ Type/Mfg .k Capacity Method of Disposal SEWAGE SYSTEM Distanceto nearest: Well Foundation Property Line ; DESTRUCTION LEACHING LINE ❑ No. & Lr'gth of lines Total length/size FILTER BED ❑ Distarce'•to nearest: Well Foundation Property.Line I+ SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distancelto nearest: Well Foundation Property Line + DISPOSAL PONDS ❑ 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. 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 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 compensation laws of California." The appI ' t must all for all required inspections. Complete drawing on reverse side. F Signed X Gr' A Title: Date:�- f�- F PA T USE ONLY Application Accepted by Area 3 ❑ Stk 466-6781 Additional Comments: ❑ Lodi 369-3621 P'IN, Grout Inspection by Date ❑ Manteca 823-7104 I. Final?In —YL-_- spection by - Date &3 L7 Tracy 835-6385 Applicant - Re urn all copies to: Fnvir nmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 1 FEE BASE 'X AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO EH 13-24 REV. 10��'4 ' �/� a �r �emc " 5 volol Wdlri�