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k. APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES TYEAR 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. Z �r { Job Address _10 if-37 (6 . E]I biy '^ o City Lot Size PM Owner's Name �7 1J� 1I7 L� Address � Phone + * Contractor174 u Address 1`-1P IC040 License No. 36 04TJL Phone TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST:.SEPTIC TANK SEWER LINES 1 001 DISPOSAL FLD. PROP. LINE �I FOUNDATION 1 AGRICULTURE WELL OTHER WELL— PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS t w ❑ industrial s ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing �\ IILDomestic/Private IkGravel Pack ❑ Tracy Jype of Casing ! Specifications .. F1 1 Public t Ll Other 171 Delta -_;Depth of Grout Seal 1-I Type;of Grout (� I I Irrigation �-Approx]Depth I I Eastern Surface Seal Installed by Repair Work Done ❑f Type of Pump H.P. State Wor one I, Well Destruction r Well Dia eter Sealing Material (top 50') I Depth Filter Material IBeiow 501 TYPE OF SEPTIC WORK: NEW INSTALLATION 1:1 REPAIR/ADDITION I I DESTRUCTION I 1 INo septic system permitted if public sewer is available within 200 feet.) !!1 Installation will serve: Residence Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth*of 3 feet: t _ Water table depth SEPTIC TANK ❑*T p0 Mfg.— 7 Capacity- No. Compartments PKC. TREA7MENT{P4T. F-1 N'Method of Disposal Distance to�pearest: Well L Foundation r Property,Line [ { �.�.. ..,.•...i.*=Ott:, i t LEACHING LINE ❑ No. &=Length of lines a +' "� Tota! length'/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line .' SEEPAGE PITS ; !,I,1Depth ; Size J'4 1,Number t SUMPS y Ll Distance to nearest: Well Foundation Property Line ' DISPOSAL PONDS ❑ s hereby certify that t 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 DiMrict. 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 Ishali 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: "!certify that in the performance of.the work for which this permit is issued, I shall employ persons subject to workman's ccmpensa- tion laws of Califor The applica ust call for all-require 'n ctions. C tete drawing on reverse side. i 1 �. 2 .q Signed X Title: date: OT MEI9USE ONLY Application Accepted by 0a, At r Date Area ` Pit Inspection`by "'P " """"D `' /�j �' `Final Inspection by Date 'd Additional Comments: 4� 3 `�` "' 00 , 4 of � ❑ Stk 466-6781 ❑ Lodi 3621 ❑ Manteca 823-7904 ❑ Tracy"835-&385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 � INJFf AMOUNT DUE AMOUNT REMITTEDH 9:x—RECEIVED BY _DOE ERMI7'NO +.EH 1EH 4-24IREV.tiH51 T' e0� I'Zod— // JfT kALb _ 9. 3 c3�