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w. APPLICATION FOR PERMIT 1. SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (205) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED it (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. 1852 for well/pump and the Rules and Regulations of the San Joaquin Local Health District., Job Address *- _ City � /nELot Size--.%S_ t CID PM- - 4-1 Owner's Name !/IfE�-�f� ' . r"Address Phone .� x�., •_ Fye A/' { Contractor's Nam14 , off S License No. PLt'' �PFione Name/"14-.2 TYPE OF WELL/PUMP: NEW WELL ❑ WEL-L REPLACEMENT 0_.. - DESTRUCTION ❑ PUMP INSTALLATION LlC SYSTEVREPAIR ❑ a �� OTHER ❑ DISTANCE TO.NEAREST: SEPTIC TANK SEWERiLINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL_ PITS/SUMPS' �_ INTENOED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industinal ❑ Open Bottom El Manteca Dia. of Well Excavation }-- _ Dia. of Well Casing J ❑ Domestic/•Private ❑ Gravel Pack _ ❑ Tracy Type.of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout _ F] Irrigation f Approx. Dept ❑ Eastern --Surface Seal Installed by- r Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material {top 50'1 Depth Filler Material {Below 501 s Q TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION DESTRUCTION ❑ (No -septic system permitted if public sewer is r_-1 ;, .. - I. available within 200 feet) Installation will serve: Residence�s Commercial_ Other �. Number of living units: Number of bedrooms x ] , r ' Character of sail to a depth of 3 feet: , 'C ;x Water table depth �5 SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ t Method of'Disposal Distance to nearest: Well Foundation I Property Line s LEACHING LINE X No. & Length of lines / 9� Z- 'AV' Total length/size FILTER BED ❑ Distance to nearest: Well - Foundation -/C? Property Line F SEEPAGE PITS ❑ Depth Size Number s SUMPS ❑ Distance to nearest: Well° Foundation E Property Line i DISPOSAL PONDS ❑ r •� 1 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. J { 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 Caiifornia." 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 applican cap for allfrequired inspections. Complete drawing on reverse ems., SignedTitle: Date: ` FOR DEPARTMENT USE ONLY i f ` Application Accepted by } ° Date 113 r' Pit or Grout Inspection by ` Date Final Inspection by i9Date ,� Additional Comments: _� OAF ❑ Stk 466.6781 ❑ Lodi 369-3821 k Manteca.,823 7104 ti .❑.Tracy 835-6385 Applicant- Returnall copies to: Environmental Health Permit/Seivices 1601-E. Hazelton Ave., 0-b'Box 2Qa9, Stk., CA 95241_ FEE INFO AMOUNT DUE AMOUNT REMITTED "'SSW RECEIVED 9Y DATE -PERM_IT"NO. r ,� + CH 3-24 Ex 14-28 41111MTOM) ,w