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I 14 APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMITEXPIRES 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 fo Local Health District. r well/pump and the Rules and Regulations of the San Joaquin 1 S ; Job Address City Lo#Size PM i Owner's Name Address o ,e-. `/ -Z Phone Contracto Address Po. License No Z17 YZ Z�n Phone (0S`P-;T G 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 i ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other C3 Delta Depth of Grout Seal Type of Grout I ❑ Irrigation —Approx. Depth ❑ Eastern Surface Seal Installed by ! W Repair Work Done ❑ Type of Pump H.P. _ _ State Work Dane Well Destruction ❑ Well Diameter Sealing-Msterial (top 50') U) Depth ( Filler Material`Below 50')A-" TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ EPAI /ADDITION DESTRUCTION'❑!(No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence Commercial°/ Other ¢ r + 3 Number of living units: Number of be rooms Tj I �.: Character of soil to a depth of 3 feet:l l Water table depth SEPTIC TANK ❑'i Type/Mfg i Capacity -L- No. Compartments � PKG. TREATMENT PLT. ❑' y f Method of Disposal I 1_ _' tS t Distance to nearest: -Well-- Foundation --- - --• .Property Line - LEACHING LINE �o. & Length of�llne. Total length/size X FILTER BED ❑ Distance to nearest: Well wo Foundation /Or Property Line SEEPAGE PITS ❑ Depth +_ Size_fir K�0 I Number SUMPS f'Distance to nearest:_,,.—Well 113-6. F l undation 40 'Property Line sS DISPOSAL PONDS ❑ l _ 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 agents signature' -certifies, following:-LI-certify that in-the-performance of the work for-which this permit is issued;I'shafl not employ any person in such manner as to become subject to workman's.compensation-taws of California."Contractor's hiring or sub-contracting signature ` certifies the following:"I certify that in the performance of,tfie warkfior which this permit is issued;I shall employ persons subject to workman's compensa- tion laws of California." ` ' _The-applicant mu alt for-all-requi in ctions.-Complete-drawing-on•reverse.'ssiide-- - � -- ---- - - - - Signed Title: J Datel-2YY&7V— lFOR DEPARTMENT USE ONLY Application Accepted by Datelk2 Area _,. ?it qrr Grout Inspection by �Da �� al Inspection by Date Additions( omfnents: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy cl 835-M s Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE y AMOUNT REMITTED INFO 1 CASH RECEIVED BY DATE PERMIT'N0. + EH14-28 V.Iiesl — EH 5428 � I