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APPLICATION FOR PERMIT �+ SAN JOAQUIN LOCAL HEALTH DISTRICT 'O's J 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 q PERMIT EXPIRES 1 YEAR FROM DATE ISSUED P(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 1 v"pOiJI ' City /44Loi Size pM Owner's Namet-f.V Address ML Ce`Phon6 1F— r ZS 7 ,- Contractor s.1 ��S� Address rEch ! 4 License No.3-27 Phan 3y—4171—f TYPE OF WELL/PUMP: NEW WELLW WELL REPLACEMENT77 DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK 100 SEWER LINES j DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL--OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION.SPECIFICATIONS ❑ Industrial El Open Bottom J ❑ Manteca Aia. of Well Excavation '- Dia: of Well Casing 6 Domestic/Private P- r'� �' !�Gravel Pack ❑ Tracy Type of Casing /� � t .,� Specifications s ❑ Public ❑ Other ❑ Delta Depth of Grout Seal_ IO 'i Type of Grout t " ❑ Irrigation —LApprox. Depth ❑ Eastern Surface Seal Installed by O ` ' R G „^- Repair Work Done 13-91—of Pump S'013 H.P. _ Z,� I State Work Done Well,pestruction ❑ Well Diameter Sealing Material {top 501 1 1 `-'U Depth Filler Material (BelowP50') E \ TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION El DESTRUCTION ❑ (No septic system permitted if public sewer is I available within 200 feet.) Installation will serve: Residence_ Commercial_ Other 1 _ _ J (fin Number of living units: Number of bedrooms �` -ti I ? �\ Character of soil to a depth of 3 feet: - � Water table depth = SEPTIC TANK ❑ Type/Mfg r Capacity' ,� No. Compartments PKG, TREATMENT PLT. ❑ .; -_ .,�� „.,,„Method of Disposal O Distance to nearest: Well Foundation Property Line 4 LEACHING LINE ❑ No. & Length of lines Total length/size ',.1 FILTER BED ❑ Distance to nearest: Well Foundation Property Line k t ` SEEPAGE PITS ❑ Depth Size Number � SUMPS ❑ Distance to nearest: . Well Foundation Property Lines ' DISPOSAL PONDS ❑ i 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 I rules and regulations of the San Joaquin Local Health District. - . . 111 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 coinpensa- tion laws of California." l" The applicant must 11call for all required inspections. Complete drawing on reverse side. _ 3 Signed Title: c Date: F R DEPARTMENT USE ONLY a L Application Accepted byZ,� (� Date C� _ Area i Pito Grou' nspection by ��._. _ Date�— 2. Final Inspection by Date Addie Comments: L� �L 4��r� (�� H.f �'-•--~ " ` C � , ❑ Stk 466-6781 q Lodi 369-3621 ❑ Mante -7104 ❑ Tracy 835-63$5 ,T f h Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 .� FEE i INFO UNT DUE AMOUNT REMITTED BH RECEIVED BY DATE PERMIT'NO. EH -24+ EH14-2BIREV.1/H5) �S t00 5-UD b ��L��JGU