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APPLICATION FOR PERMIT �. z SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON 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/pump and the Rules and Regulations of the San Joaquin Local Health District. ` Job Address City —"�MNLOt Size _)O k Z PM Owner's NameFICAlA rlez ie/ -address Phone V6&'l2. p Contractor's Name Ai/:aJ,1 License No. 4L,4 Phonez/6 6197 TYPE OF WELL/PUMP: _NEW;'WELL'r❑�,..;0 WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ BOTHER Cl DISTANCE TO NEAREST: SEPTIC TANK - — -w _ SEWER LINES "'" DISPOSAL FLD. PROP. LINE " FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE: ,YPE.OF,WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS- El Industrial Y ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other I ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation -L—Approx. Depth p Eastern Surface Seal Installed by y Repair Work,)]one:` ❑ fT4e-of'Pumpl j H.P. State-"Work-Done —' Well Destruction ❑" )Well — _e Sealing Material (top 501 s Depth ~t Filler Material Welow 50) TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION K DESTRUCTION ❑ (No septic system permitted if public sewer is available withih 200 feet.),: [k Installation will serve: Residence Commercial_ Other I !� } Number of living units: ___/_ Number of bedrooms Character of soil to a depth of 3 feet: I � Water table depth' SEPTIC TANK ❑ Type/Mfg f Capadity'' No."Compartme�its " PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation'---. Property Line LEACHING LINE No. & Len nth of lines g � "'" �Q � Total length/size FILTER BED ��❑ Distance tc`nearest: Well Foundation 10 Property Line /!17 r SEEPAGE PITS ,V9. Depth .-`Size Re,', f� _,Number l SUMPS ❑ Distance to'nearest: Well Foundation /92 Property Line ' DISPOSAL PONDS F7 � ",r ,,. I hereby certify that I have prepared this application and that the work will be done in accordancelakth San Joaquin county ordinances, state laws, and k 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 workmarYs compensation laws of California." Contractor's hiring or sub-contracting signature certifies the•foll rigs=_'I-certify-that in`the rformance of the work forwhich this permit.is issued,-1 shall-employ persons subject to workman's compensa- tion laws of Cal' rnia." *— The applican u call for required ' -pe ns. Complete dra 'ng everse side. "Signed Title: FOR DEPARTMENT.USE ONLY AppEication Accepted by T 1 T r Date "$ 1 rea ©3 - ' ` ;-+ �• . -it-or-Grout Inspection"b te3•�- "•y Final Inspection b - - __._pate --`:� Additional Commen '- / t ❑ Stk 466-6781 ❑ Lodi 369-3621 D Manteca 823-7104 ❑ Tracy Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY /DATE P`E1RMIT`NOG.FEE " + EH 13-24 1REV. 101831 EH 1426 s Q w'] �_ 3/�f 5(;t1 ��►�"� 4