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j APPLICATION FOR PERMIT SAN JOAQUIN:LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA 's Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED , (Complete inTriplicate) 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 Ryles and Regulations of the San Joaquin Local Health District. Jab Address City a Lot Size ��0 PM 92E2 r_L , Owner's Name E/ 70 )4 /4- Address r Phone 9 Contractor 4�w/ `JAddress License No. Phone 37�s767 ` TYPE OF WELUPUMP-: NEW WELL WELL REPLACEMENT DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER. ❑ ` DISTANCE TO NEAREST: SEPTIC TANK //Sd SEWER LINES `.�Sd DISROSAL'FLD:� PROPS LINE /_9 f FOUNDATION 2 AGRICULTUFUE WELL OTHER WELL Q_.__ PITS/"SUMPS "°�/V INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS r, ❑ Industrial ❑ Open Bottom n;-Manteca Dia. of Well Excavatiori',C,2" Dia. of Well Casing (117 �mestic/Private gavel Pack TT❑ Tracy Type of Casing_r__ —c��o Specifications \ El Public ❑kOther Ll Delta Depth of Grout Seal ri S!�`� - - Type of Grout r t i r3- ! r. V ❑ Irrigation I /�Approx. Depth) ElEastern. Surface Seal Installed by ' _ State Work Done ♦ •^+ O epair one ❑ Type of Pump .Sc�h H.P. r a-f .., j� U! 61 Destr on Well Diameter 'J!;-, i-Sealing /Material (top 50') ! W Depth "Filler Material (Below 501 T PE OF SE TIC WO K: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic'system permitted if public sewer is available within 200 feet,) ns ion will serve: Residence Commercial_ Other - i Number of living units: Number of-bedrooms Y 11 Character of soil to a depth of 3 feet: } I Water table depth SEPTIC TANK ❑ Type/Mfg Ir' Capacity I No. Compartments PKG. TREATMENT PLT. D---- —MiAcd of Disposal j Distanc't o nearest: Well Foundation Property Line LEACHING LINE LLi No. & Length'of lines Total length/size FILTER BED ❑" Dista cn a to,nearest: Well Foundation — Property Line SEEPAGE PITS — ❑---Depth -Siie "" Number SUMPS ❑ Distance to nearest: Well Foundation Property Line , 'i DISPOSAL PONDS ❑ 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'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." The app' mu t call for all required inspections. Co3piplete drawing on reverse side. -} Signe Title: Date: . FOR DEPARTMENT USE ONLY �j�� Application Accepted by Date Area �� ,' $ Pit or Grout Inspection by Date Final Inspection by Dara Additional Comments: ❑ Stk 466-6781 O 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 AMOUNT DUE AMOUNT REMITTED CK# RECEIVED BY DATE PERMIT`NO. INFO CASH + EH 13-24(REV.I/H 5) �� g o Sl FsS F EH 14-26 '