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i APPLICATION-FOR PERMIT o_ SAN JOAQUIN-LOCAL. HEALTH DISTRICT >� 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED wW E., ,z -(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.,. . . ; p�nf.,tom Ci q ._J_lL r~4 _/— x Job Address _ f ty �V Lot Size�,L ' PM ,l Owner's Name O /�Q ��/t�J Address 330' 13A& ��jPhone Contractor's NLicense No. P�' � — Phone r TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ ---•--PUMP INSTALLATION • -SYSTEM REPAIR E1-- OTHER-0- DISTANCE TO NEAREST: SEPTIC-TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL ` PITS/SUMPS } INTENDED USE TYPE OF WELL A PROBLEM AREA CONSTRUCTION SPECIFICATIONS Q industrial ❑ Open Bottom ❑'Manteca Dia. of Well Excavation pia. of Well Casing Domestic/Private ❑ Gravel Pack k '(7 Tracy Type of Casing d Specifications I. �y LI Public El Other ❑ Delta Depth of Grout Seal Type of Grout N ❑ Irrigation ---Approx. Deptht� '" ❑ Eastern Surface Seal Installed by_ I C.- ,, `` J - i Repair Work Done ❑ Type of Pump I e H.P.--."_ State Work Done Well Destruction ❑ Well Diameter .f Sealing Material (top 501 i r Depth 1 Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer.is I 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: Water.table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line �. i _ r LEACHING LINE ❑ No. & Length of lines Total length/size l FILTER BED _E]—Distance'to nearest: Well Foundation Property Line Y' -SEEPAGE-PITS ❑ -Depth--- A—E�, ^Size :,r.`' ."e' 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-countyl-n�dlnances,-state laws, and rules and regulations of the San Joaquin Local Health District. 1 t, 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 notr employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature - cert'rfies 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 applicant mu 11 forll uir ins ction omplete drawing on rev side. Signed X Title: .. Date: � u1 FOR EPARTMENT USE ONLY Application Accepted by (JV/C. Date ^' Z-7 Area Pit or Grout Inspection by y Date Final Inspection by �``� Date''�l Additional Comments: ❑ Stk 4615-6781 }– ID Lodi 369 36'11 ❑ Manteca 82'3-7104 -❑ Tracy -835-6385 * 4 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk:t:A FEECK INFO `'AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT`NO. + EN 1324(REV"101331 $5 EH 4428 i lcnZ-1