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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete'in Triplicate) ' p' Application is hereby made to the San Joaquin Local Health District for a, upermit 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. ' - }.: .+, tc, ,e r.• !. v . r Job Add ressl I'lRlu'aE;2 n F' Ep a� Gity_�i�y� Lot Size PM Owner's Name (Lelly OF RIPON -Address W,J.': T_S"T � ��i� Phone ASS` - fOij Contractory fA�.fL4'�( Sf Address © V Ir t>q_. License No.M025 Phone s TYPE OF.WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT L7 DESTRUCTION ❑ PUMP INSTALLATION J!� SYSTEM REPAIR.❑ OTHER ❑ �r DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE _ FOUNDATION AGRICULTURE WELL_ OTHER WELL PITS/SUMPS._, INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS �� ❑ Industria! ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ;4 Gravel Pack ❑ Tracy Type of Casing Specifications e Ok Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout � ❑ Irrigation ---Approx. Depth a ❑ Eastern Surface Sea! Installed by Repair Work Done T54 Type of Pump ML2_ ME H,P- State Work one Well Destruction ❑ Well Diameter Sealing Material (top 50') =NsT�J// sf� � '� 1pA Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available.within 200 feet.) , Installation will serve: Residence` Commercial Other A Number of living units; Number of bedrooms I �� Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg '' F "' Capacity No. Compartments PKG. TREATMENT PLT.❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines g Total length/size FILTER BED ❑ Distance to nearest: -r Wel! Foundation Property Line SEEPAGE PITS ❑ Depth Size `" r" Number + SUMPS Q Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ d _ hereby certify that I ha_ye prepared_this application and,that.the-work will-be done-in=accordanae-with'San`doaquin county-ordinances,-stafe laws, and f rules and regulations of the San Joaquin Local Health District. Horde 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." Contractors 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."-r The applicant.must call for all required inec'ons. Complete drawing on reverse side. Signed Title: 6 � Date:..... OR DEPARTMENT USE ONLY Application Accepted by (f'�� 4 Date !'rAiea • tai Pit or Grout Inspection by Date Final inspection by �j SS Date y Additional Comments: ,rr r g w 7 E ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95209-, iii FEE AMOUNT.DUE AMOUNT REMITTED RECEIVED BY DATE =0tRMtT"NO. 'INFO + EH 13-24(REV.1/a 5) EH 14-26 SS—�0 b