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tit td �. APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA y Telephone (209) 466-6781 I' PERMIT EXPIRES 1'YEAR FROM DATE ISSUED IComplete 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. L ` p Jab Address o��- `'1 l��f b City^?—A2\O—A Lot Size II PM Owner's Name � Address Phone If P.o. `�g Contractor 1t1{�ZAddress7�A�. �fY'LWXW 44 License No�� Phone � I TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION �❑ SYSTEM REPAIR El OTHER LJ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES SCR9 f DISPOSAL FLD.540 t PROP. LINE•Sod t FOUNDATION.5 AGRICULTURE WELL OTHER WELL AS PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS II 3 ! ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Ae Dia. of Well Casing /8 j ❑ Domestic/Private Gravel Pack Tracy Type of Casing • trl� Specifications FPublic f 3 Other ❑ Delta Depth of Grout Seal Type of Grout irrigation &5M..Approx. Depth l I Eastern Surface Seal Installed by 11W Repair Work Done Type of Pump _..... _A, H.P. Slate Work D e_ Well Destruction ❑ Well Diameter Sealing Material Itop 50') L1,J ruv� Depth Filler Material (Below 50') i TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION l I DESTRUCTION I 1 INo septic system permitted if public sewer is / j available within 200 feet.) Installation will serve: Residence_ Commercial_ Other -7 Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth ! i SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS f I Depth Size Number C SUMPS Ll Distance to nearest: Well Foundation Property Line e 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. b 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 I employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature 1 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 applica mus or all required inspections. Complete drawing onTreverse Jside. ^7 Signed �� Title: 1�� !P11'G%A-P7 Date: �/ I FOR DEPARTMENT USE ONS, Application Accepted by ate n X -I Area 6 Pit or Grout Inspection byDat Final Inspection by 4 Date Additional Comments: oll Z7 *r' e it Cl Stk 466-6781 ❑ Lodi 369469 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Silk., CA 95201 I FEE AMOUNT DUE AMOUNT REMITTED CKA) RECEIVED BY DATE PERMIT NO. INFO `� CAJS�H! /- + EH 13-24(REV.I/K51 �O � UCS I1�1b AD 3— EH 14-2a !!! I