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r APPLICATION FOR PERMIT I SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA $ Telephone 1209) 466-6781 j 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 San Joaquin Local Health District. Q " Job Address v City Lot Size PM Owner's Name • ryd�� Address L Phone ConIfacIor L. AddressAl 1�40JWAQV License No. Phone l TYPE OF WELL/PUMP: IIEW WELL ❑ WELL REPLACEMENT 11 DESTRUCTION I 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 j Industrial EIOpen Bottom LJManteca Dia. of Well ExcavationDia..of Well_Casing_ Domestic/Private LlGravel Pack ❑ Tracy Type of Casing Specifications CP f 1 Public ❑ Other 1 Cl Delta Depth of Grout Seal Type of Grogt _ I I Irrigation _..Approxi Depth` t I Eastern ?'Surface Seal.lns,called by l _ Repair Work Done ❑ Type of Pump H.P. State Work Done, Well Destruction Well Diameter , ,Sealing Material !t p�50'F_::= Depth { Filler Material (Below 501,7- TYPE 0'1,"'TYPE OF SEPTIC WORK: NEW INSTALLATION I I»REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.] Installation will serve: Residence Commercial_ Other - Number of living units: Number of bedrooms t Character of soil to a depth of 3 teen f h `�+ Water table depth SEPTIC TANK ❑ Type/Mfg Capacity— No. Compartments PKG. TREATMENT PLT. ❑ __ ,r Method of Disposal Distance to nearest: Well Foundation Property Line r LEACHING LINE ❑ No. & Le+gth of lines } Total length/size FILTER BED ❑ Distance to nearest: Well; Foundation Property Line 1 SEEPAGEPITS—I I "Elepth '""""" Siza— `Number SUMPS L] Distance to nearest Well Foundation Property Line DISPOSAL PONDS ❑ 1"herebycertify that I have prepared t�iis application and`thaC i�ie wo�k`will-be done in accordance with'-$an Joaquin county ordinances,state 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 perso 'n such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature certifies the foil in : "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 for ta," 4 The applic t t caH for all re ed ins t ns. Complete drawing on side, ev Signed X Title: Date: OR D PARTMENT USE ONLY i I Application Accepted by Date Z-- rea L Pit or Grout Inspection by Date Final Inspection by r"" Date t Iq Additional Comments: I �[� r VIdt ❑ Stk 466-6781 ❑ Lodi -3621 ❑ Manteca 8,23-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE' AMOUNT REMITTED CASH CK 0 RECEIVED BY DATE ' PERMtT*No. # a.EH 13-24/REV.1/"51 i Fi14-28 W Q A Qf / -00 4�