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APPLICATION FOR PERMIT M-77 SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA I M Telephone (209) 466-6781 j PERMIT EXPIRES 1'YEAR FROM DATE ISSUED (Complete in Triplicate) Applicin ation,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 compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and the Rules and Regulations of Local Health District. the San Joaquin ' Job Address 01 City Lot Size PM Owner's Name A dress • � Contractor Address Phone TYPE OF WELL/pU P: NEW WELL E2 rise No Phone PUMP INSTALLATION ❑ WELL REPLACEMENT DESTRUCTION DISTANCE TO NEAREST: SEPTIC TANK SYSTEM REPAIR ❑ OTHER ❑ SEWER LINES y DISPOSAL FLD. FOUNDATION. AGRICULTURE WELL PROP. LINE INTENDED USE OTHER WELL PITS/SUMPS TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Ll Industrial ❑ Open Bottom ~— of O ❑ Manteca Dia. Well Excavation ❑ Domestic/Private ❑ Gravel PackP-Tracy- -.Type of CasingDia, of Well Casing (1 Public n OtherSpecifications I I Irrigation n Delta Depth of Grout Seal —.-Approx. Depth I I Eastern Surface Seal installed by Type of Grout Repair Work Done ❑ Type of Pump Well Destruction ❑ Well DiH'P State Work Done_ T Diameter ._� Sealing Material (top 50'1 � CJ 11111 Depth Filler Material f Below TYPE OF SEPTIC WORK: NEW INSTALLATION l 1 REPAIR/ADDITION DESTRUCTION I 1 ffJo septic system permitted if ublic Installation will serve: Commercial,— .Other_Residence ' available within 200 feet.! P sewer is �- �.,,_ _ _ Number of living units: Number of bedrooms . ~- Character of soil to a depth of 3 feet: SEPTIC TANK ❑ Type/Mfg a Water table depth PKG. TREATMENT PLT. ❑ ""Capacityr No. Compartments r -4 . Distance to nearest: Well Foundation Method of Disposal Property Line LEACHING LINE ❑-. No. & Length of lines., FILTER BEDTotal length/siz Die O stance to:nearest:-- —Well -Foundation- -, r Property Line SEEPAGE PITS I I Depth Size r " 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 county ordinances, state laws, and rules and regulations of the Sari Joaquin Local Health District. w 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 m ca all-Pp llr uire s ions. Complete drawing on rMse side. Signed X Title: � __ — Date: i FOR DEPARTMENT USE ONLY / Application Acceptvy _/z I c Date l0~ Q r Area Pit orGroutInspection by Date Final Inspection by Date Additional Comments:�f ❑ Stk - � 0/1 a ve enface 823 7104 ❑ Tracy 835-6385 1`r" N�7}Gt r Wlk dVM Wo (f IRM Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box Stk., CA 85203 Sksh FEE gMOUNT DUE CK INFO AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. + EH 13-24(REV.t i H 5) / � I EH 14-26 C.A W7 �C