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s• � APPLICATION FOR PERMIT Ll<_ SAN JOAQUIN LOCAL HEALTH DISTRICT c 1601 E. HAZELTON 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 compliance with San Joaquin County Ordinance No.549 for sewage or No. 1BG2 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address City 9 Lot Size PM el Owner's Name" ,/ii, 71.Q1Q/ Address �-3`t` �37�1- ,��C fav vj- Phone Contractor )317 119 Address License No/6 22 2_3 Phone tGI W/ TYPE OF WELL/PUMP: NEW WELL Eii� '. ; WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION � 1 SYSTEM REPAIR ❑ OTHE� ❑ DISTANCE TO NEAREST: SEPTIC TANK --� SEWER LINES I 60 / DISPOSAL FLD.:2t24-' PROP. LINE 1-''___ FOUNDATION AGRICULTURE WELL r OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA. CONSTRUCTION SPECIFICATIONS El Industrial . -_ _.__❑-l3pen_Botto1]1at -Manteca Dia. of Well Excavtan _ �I _ _ Dia. of-.Well Casing. r J'Domestic/Private 11;,dravel Pack ❑ Tracy Type of Casing Specifications t M Public 171 Other fl Delta Depth of Grout Sea: ?: 't�- Type of Grout I I Irrigation Approx. Dep I I Eastern Surface Seal Installed by _ Repair Work Done ❑ Type of Pump. H.P. State Work an Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 501 �_ TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I {No 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: Wat,r table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. O ! Method of Disposal Distance to nearest: Well FoundationProperty Line LEACHING LINE ❑ No. & Length of lines Total length/size 1 FILTER BED CI Distance to nearest: Well Foundation Property Line SEEPAGE PITS I 1 Depth Size Number SUMPS ❑ Distance to 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 signaturWcertifies 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 lavvs-af California." The applicant mus I fbE all required In ctions. Complete drawing on reverse side. / �J q Signed X - �` itle: Llrf Date: r FOR R DEPARTMENT USE ONLY Application Accepted by Date Area Z t' a- Pit or Grout Inspection by ate 1��l a�' Final Inspection by Date Z4/JV Additional Comments: ❑ 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, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED ,CASH RECEIVED BY DATE PERMIT'NO. r EH13-24(REV. /n 51 O 9 .y E EH 14-28 �""1