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z , APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT ; 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 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/pumand th Rules and Regulations of the San Joaquin Local Health District, �'/� � 1 Job Address c2!?6 q o 2"t-A1/ 1 ,e CKV7 - Lot Size PM i Owner's Name jG� � r` ��`7 Address 16 4 + Q Rd, [.�IR-hone Contractor S rl�itr Address i IbPys;r Rat Ab�License Nom^7s��l Phone�2Z�/1�r�3 � TYPE OF WELL/PUMP: N W WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ 1 PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ - DISTANCE TO NEAREST SEPTIC TANK I�- SEWER LINES l09'��DISPOSAL FLD. '� PROP LINE 1 �Y FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL s PROBLEM AREA CONSTRUCTION SPECIFICATIONS �� 9 E] Industrial LJ Open Bottom '❑ Manteca Dia. of Well Excavatio Dia. of Well Casing. ' ❑ Domestic/Private ,(Gravel Pack ID Tracy Type of Casing Specifications f_N r"� InJ _ f`l Public Cl Other�.7.� C7 Delta Depth of Grout Seal ��{{ ,,t pGi�em Type of Grout �+'t- F _ '�trrigation Approx. D th l I Eastern Surface Seal Installed by 1 Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction i❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIRIADDITION l I DESTRUCTION l 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 \ Character of soil to a depth of 3 feet: Water table depth T SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal i Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size - Number SUMPS -—Distari-ce to nearest: Well Foundation Property Line DISPOSAL PONDS 0 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 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."Contractof'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 applicant must call for all required inspections. Complete drawing on reverse side. Signed X i1 tfL � Title: ��n I l to A Date: f OR DEPARTMENT USE ONLY / '15/ Application Accepted by / f / Date Area / Pit o Grob Inspection by Date%7 �/ Fina! Inspection by,' Dated/ice Additional Comments: ❑ Silk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Sik., CA 85201 FEE INFO AMOUNT DUE AMOUNT REMITTED CA RECEIVED BY DATE PERMIT No. + EH 13-24(REV.t/a 5) EH 14-26 YI-T/ 9,0-11 I