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yam. APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CAe � Telephone (209) 466-6781Aik PERMIT EXPIRES 1 YEAR FROM DATE ISSU D r ri (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct and i ll?the v9o0he ein desci'ibe>i. This application is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pdrp d i�^rgF} les a c` g_6164&of the San Joaquin Local Health District. r��s X41 Job Address L] I tD ( . Q O L 1 f City Q,.kLot Size Z LAi PM Owner's Name [\ � �L-�� Address R1� t�. t��L�1E Phone r d Contractor UOS V- L i2Address License No.a (/Phone_ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT DESTRUCTION PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER ❑ 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 0 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing X)omestic/Private © Gravel Pack `❑ Tracy` ` Type of Casing Specifications I'] Public Ll Other ❑ Delta Depth of Grout Seal Type of Grout _ I I Irrigation _.-Approx. Depth I I Eastern Surface Seal Installed by _ _ Do Re �LFPt pair Work Done ❑ —Type of Pump 5U g_ H.P. — 3'1 State Work Done — -- _— — -- WorkWell Destruction ❑ Well Diameter Sealing Material {top 50') Depth — Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIRIADDITION l I DESTRUCTION I I INo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_ Other �J i 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 ❑ Distande to nearest: Well Foundation Property Line 5 1 SEEPAGE PITS I I Depth Size Number SUMPS Ll Distance to nearest: Well Foundation Property Line I -" DISPOSAL PONDS,r;,.�0— .� r _.. _ ,�T. �... s ..• —r: .� -�: 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 regulatioKs'of'the-San Joaquin LOCal-HBattli Dl$tfitt. 9 Flame 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-lawsJC�alinia." The,applicall for all rered inspec ns. Complete drawing o rave a sideI5igrjed Xs Title: Date u FOR DEPARTMENT USE ONLY Application Accepted by Dat 1 Area Pit or Grout Inspection by a Final Ins ectio� 1' Date CF( Additional i i Additional Comments: -; ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6365 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE l INFO AMOUNT'DQE F AMOUNT REMITTED H" "' RECEIVED BY DATE PERMIT'NO. r EH 3-24 EH 1�29 IREV.5/x 51 e,� i / q 1�.`o { S ^CI