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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 IS SUED (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 Add ZOO ZOI�� d 4 .p �� .^ City t /� Size PM j` i Owner'sName D�14&1 �/' �iV[Address 1_V Phone E L Contractor.sName GLt`+'[[�� P nse No. —37/s��6 Phone TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT L7 DESTRUCTION ❑ , PUMP INSTALLATION SYSTEM REP IRC] OTHER DfSTANCETQNEAREST: SEPTIC TANK_ ) _ _ SEWER LINES '�� DISPOSAL_FLDr# PROP. LkNE ��Q FOUNDATION ) AG RICULTURE�WELL� OTHER WELL PITS/SUMPS �~ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICA ❑ Indd rial ❑ Ope ottom ❑ Manteca Dia, of Well Excavation Dia. of Well Casing hYDomestic/Private ravef Pack ❑ Tracy Type of Casing s / ` —Specifiicatons w� ❑ Public , ❑tether ❑ Delta D_ep-h of�rout Seal Type of Grout ��+ ❑ Irrigation --4pprox. Depth Eastern S Seal Installed by I^&# -+ i Repair Work Done ❑ Type of Pump 1 H.P._ State Work Done �Iu(q�d t I k - Well Destruction❑ Well Diameter Sealing Material Itop 50'i: # Depth Filler Material I13elow,50',) TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ 1 REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is k t available within 200 feet.) ~ ;j=t" Installation will serve: Residence— Commercial— Other �4aNumber of living units: Number of bedrooms Character of soil to a depth of 3 feet: �—V1/atertable depth 0 --_ —SEPTICTANK_ ❑ Type/Mfg, ` Capacity No. Compartments PKG. TREATMENT PLT. O i Method of Disposal '°""-'""""""Distance`f"earest: Well Foundation, ,x� Property Line r' LEACHIN G LINE ❑ No. & Length of linest _= Total length/side+ ..s• FILTER BED CI Distance to nearest: :Well Foundations ' 'Property Line SEEPAGE PITS ❑ Depth (Size Number �� ' SUMPS i ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 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 Isuchn man er as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature certifies the following: e '. th in a performance of the work for which this-permit is issued, I shall employ persons subje t t rkman's comtion laws of CaliforniaThe applica t t cr e s is C mplete drawing o r v�rs side. Sign /1`' 9 Title: Date: j FOR DEPARTMENT USE ONLY _Appliication Acceptad by Date - Area ` Pit_or Grout Inspection by �Date3❑ Final Inspection by Date Additidhal`Comments: U(Stk 46BV81 ❑ Lodi 369-3621 ' ❑ Manteca 823-7104 [ Tracy 835-63855 Applicant- Return all copies to: Environmental Permit/Services 1601 E.°Hazelton 4e-.L, P.O. Box 2009, Stk., CA 95201 -FEE AMOUNT DUE' AMOUNT-REMITTED CK RECEIVED BY DATE PERMIT"NO. INFO CASH i f, �/ r + EH 1324 SREV.10/831 ' _��/ ( � q5`-43-r J EN 1428 t �� : � ` , o J I�S ,3 iF