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�. /� Ud '. APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT z Y 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 I ,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 Sari Joaquin I; Local Health District. Job Address IL�o s City O rLot Size M�S00 L PM c -%* LZ Lks.. 1"10 Owner's Name � 1"t Address 4M SQ • Phone a 4 *� Gr-..S}) 05� Contractor 1"L �Q Address 1.�� E `4�"�Ol`� License No.43�ad9 Phone 3� TYPE OF WELL/PUMP: NEWWELL © WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM; Fj�pAIR ❑ fir`bl'tit, ¢Th ER ❑ F DISTANCE TO NEAREST'SEPTIC TANK SEWER LINES ��17 ;r-' DISP SA Fl�:wQ� PROP. LINE flll FOUNDATION AGRICULTURE WELL OT ER WELD40 ITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Zt ❑ Industrial ElOpen Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casin ` ❑ Domestic/Private Gravel Pack © Tracy Type of Casing Q�_�✓ � Specifications tl� F] Public 17 Other a 17 Delta Depth of Grout Seal T _- Type of Grout i i� I I Irrigation _Approx. Depth I ) Eastern Surface Seal Installed by �1��t�0.� �'� � 1 _ Repair Work Done L7 Type at Pump, H,P. State Work Done Well Destruction ❑ Well Diameter �- sealing Material (top 50'1 M0M�0'<1� Depth n� 3p3n)z- Filler Material IBelow 501 -. TYPE OF SEPTIt WORK: EW INSTALLATION ['I REPAIR/ADDITION E,I DESTRUCTION I I iNo septic system permitted if public sewer is a available within 200 feet.) Installation will serve: Residen ' Commercial_ Other Number of living units: NO er of bedrooms t� Character of soil to a depth of 3 feet: Water table depth { „ SEPTIC TANK ❑ Type/Mfg r Capacity No. Compartments \J� PKG. TREATMENT PLT. ❑ E Method of Disposal t Distance to nearest: ell Foundation Property Line N LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line \\\ d SEEPAGE PITS I 1 Depth Size 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, statel,laws, and rules and regulations of the San Joaquin Local Health District. 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." Contractors hiring of sub-contracting signature t 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 must call for all required tions. Complete drawing on reverse side. Signed X Title: Date:. 4�r 0. - la c auta..� FOR DEPAR ONLY 1 14 Application Accepted by a.vT -(5, Date -�- CCa /Area _ Pit or Grout Inspection by 5 Date inal Inspection by P3 S`�Uy Date Additional Comments: ' ' ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 923-7104 ❑ Tracy 935-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT'NO. INFO r EH 13-24 4REV.1/H 5) � ` ko �� EH 1428