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APPLICATION FOR PERMIT ,"' " SAN JOAO,UIN:LOCAL HEALTH DISTRICT 4 1601,E. HAZELTON AVE., STOCKTON, CA j Telephone (209) 466-6781 i 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. 1862 for well/pump and the Rules and Regulations of.the San Joaquin Local Health District. Job Address 1 7. [l _J`� LL41t2w' �>...,+{ c-f City Lot Size isy)(� f PM S "Owner's Name" _ t` _ Address Phone A Contractor --"Address License No. 2. Phone gJ_(1-7W TYPE OF WELL/PUMP:'"''" .NEW WELL �, - " 'WELe REPLACEMENT ❑ DESTRUCTION El -PUMP,INSTALLATION 04� SYSTEM REPAIR-0 OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK _ SEWER.LINES" DISPOSAL FLD7��`� PROP. LINE /-FOUNDATION f'""AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE__— T`ti(PE OF WELL PROBLEM AREA " CONSTRUCTION SPECIFICATIONS y ❑ Industrial ❑ Open Bottom Q Manteca Dia. of Well Excavation Dia. of Well"Casing 1Domestic/Private 'Gravel Pack 'Tracy Type of Casing r�� Specifications r�,: Cl Public LJ Other I ❑ Delta ` Depth of Grout Seal Type of Grout ❑ Irrigation --Approx. Dept z' ❑ E stern Surface Seal Installed by LZ Repair Work Done ❑ Type of Pump H.P. ��` State Work Done Well Destruction El Well Diameter t Sealing Material itop•509 a Depth 1 Filler Material {Below;501} i TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ .DESTRUCTION ❑ ,(No septic system permitted if public sewer is CCC777 ?available within 200 feet.) Installation will serve: Residence— Commercial, Other " Number of living units: Number of bedrooms t 4 Character of soil to a depth of 3 feet: 1 ' Water,table depth SEPTIC TANK ❑ Type/Mfg Capacity - No. Compartments PKG. TREATMENT PLT. ❑ i Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of linesftt 1. i Total length/size FILTER BED ❑ Distance to nearest: Well ? s -- -Foundation- *Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: . Well FoundationProperty 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 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 applicant st call for all required inspections.;Gomplete _drawing on reverse side, ! € Sign X Title: w s�-� Date: ti ! -FOR'DEPARTMENT USE ONLY Application Accepted by pr j t Date 'Z' [3+� Area Pit or Grout Inspection by -" Da Final Inspectio y'" �" `^.Daate �.�y Additional Comments: ) ❑ Stk 4664781 .O-Lodi..389-3621 _._._❑.'Manteca..,;823-7104,,,:.. Tracy 835-6M. ,e- Applicant- Return all copies to: Environmental Health Permit/Services 1801 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 INFO AMOUNT DUE AMOUNT REMITTED CASH CK 0 RECEIVED BY DATE PERMIT'NO. + EH13-24(Rev.I/e s) EH 11428 t _! r r^../' �'"'ID