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J ' a APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 7'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 / S [� f City MR� Lot Size Z ` PM l r j I Owner's Name Address r/S� �[I /� f Phone ;I Contractor . AddresXb� License R4Phones"22--,4 TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT;K DESTRUCTION ❑ l PUMP INSTALLATION ,x SYSTEM REPAIR ❑ l OTHER ❑ / DISTANCE TO NEAREST: SEPTIC TANK.`f SEWER'LINES �.�"�� DISPOSAL FLD. PROP. LINE FOUNDATION _ AGRICULTURE WELL OTHER WELL,;b PITS/SUMPS - s r INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS �l Ll Industrial ❑ Open Bottom Manteca Dia. of Well Excavation //_ Dia. of Well Cas' Domestic/Private jj7�Gravel Pack ❑ Tracy Type of Casing /may C_ "'/�'jf g© Specifications U2�5_ 1466 l'1 Public', Cl Other Cl Delta Depth of Grout Seal _/GAB Type of Grout`. . f I Irrigation —.-Approx. Depth l I Eastern Surface Seal Installed by Repair Work Done ❑. Type of Pump.l H.P. State Work Done_ Well Destruction ❑ , Well Diameter I� Sealing Material [top 50 Depth rF Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION l I DESTRUCTION i I Wo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ iCommercia!_ -Other"" Number of living units: Numb&i of bedrooms _ Character of soil to a depth of 3 feet: - Water table depth SEPTIC TANK '~ ❑ ,Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. 0, R Method`of Disposal Distance toln aresV Well Foundation Property Line- r it LEACHING LINE ❑ : .RZA Lengi�of lines Tata) length/size FILTER BED (11tDistance-to nearest: Well Foundation Property Line _ l SEEPAGE PITS t (1_.I I Depth--..i Size Number R SUMPS ' Cl Distance to rieatest: Well Foundation Property Line DISPOSAL PONDS xa ❑ I t, 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 Locat Health Di1trict. J - 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." I i The applicant u `call f r all requirb inspe tions. Complete drawing on reverse side. 1 ` `�j I Signed X Title: �� [�iD Date: / _4 Zt-' FOR DEPARTMENT USE ONLY # Application Accepted by Date I? t Area Z (J Pit or rout nspection by dDate �s Final Inspection by Date d Additional Comments: .�6��/fn 44;1 ❑ Stk 466-6781 ❑ Lodi 369-3621 1 ❑ Manteca 823-71 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 I , i FEEACK INFO MOUNT DUE AMOUNT REMITTED CASH RECEIVED 13Y DATE PERMIT'NO. r Y ` +.EH 13-24(REV.1in5Y n�:iEH 14-20 r S 7