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• 1 APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 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 Citye70�116_ Lot Size PM Owner's Name t �sd�Ti ez�– lam Address 10121 �r 5�LTJ./�, ; Phone Contract Address,,�&ARV TYPE OF WELL/PUV. NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER Z>7a4/fc� 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 C Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private 177 Gravel Pack ❑ Tracy Type of Casing Specifications Q 1-1 Public f] Other ❑ Delta Depth of Grout Seal Type of Grout 1 1 Irrigation --Approx. Depth l I Eastern Surface Seal Installed by _ Repair Work Done ❑ Type of Pump �- H.P. State Work Done Well Destruction $- Well Diameter 'I Sealing Material {top 501 ` Depth Filler Material (Below 501 d f TYPE OF SEPTIC WORK: NEW INSTALLATION ( I REPAIR/ADDITION I ) DESTRU O 1 (N eptic system permitted if pu6fic sewer is 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 LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS i I Depth Size Number SUMPS Ll 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 county ordinances, state laws, and rules and regulations of the San J u1 Local Health District. Homo owner or licensed agen ' signat a 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 suc anner a o become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the following: ' certif n the performance of the work for which this permit is issued,I shall employ persons subject to workman's compensa- tion laws The . an st c I fo req inspections. Com a drawing on re side igned X Title: Date: FOR DEPARTMEN USE 04 Applic on Accepted by w D te12'^ 6t_ Area Pit or Grout inspection by Date ,., Final Inspec n by Date' Additional Comments: p7` ?17 �� C-�i'�0, C7 Stk 466-6781 ❑ Lodi 369-3621 Cl Manteca 1323-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazalton Ave., P.O. Box 2009, Stk., CA 95201 INFOFEE AMOUNT DUE AM UNT REMITTED CASH RECEIVED BY DATE PERMIT-NO. ♦ EH 13-241REV.1/H51 /G�� EH 14.29 ,d 7 '