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i APPLICATION FOR PERMIT !: SAN JOAOUIN LOCAL HEALTH DISTRICT I 1601 E. HAZELTON AVE., STOCKTON, CA !' -Telephone {209} 466-6781 !! PERMIT EXPIRES'1`YEAR FROM DATE ISSUED" ,[COmplete�in,Tri L+r plicatel ,3 4 , 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 sew a or No-.1862 for well/pump and the Ryles and Regulations of the San Joaquin Local Health District. . 9 3b,av►r� g1l;Q T , Iru>< aw c .��. • ,: ,n t� f MA qi�, f,�Ja lid'�lvI ��•;, Job Address City Lot Size PM Owner's Name J® rt ��' . - Address [ _ Phon�T� . .,, JJ `/ -7� Contractor ec A. Address License NO.f3'T`3�Phon 15 �l.� TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ jo PUMP INSTALLATION ❑ SYSTEM REP IR ❑ OTHER DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE _ TI ;�. FOUNDATION AGRICULTURE WELL OTHER WELI_Lk��yPITS/SUMPS s INTENDED USE -II TYPE OF WELL - PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ;I ❑ Open Bottom ❑ Manteca Dia.,of Well Excavation /h I Dia. of Well Casing Gravel Pack ❑ Tracy Type of Casing V C.- Specifications • ❑ Public it ❑ Other ❑ Delta Depth of Grout Seal 4 . • ype of Grout �T e ❑ Irrigation 50_1q�Approx. Depth ElEastern Surface_Seal Installed by Repair Work Done ❑,S Type of Pump H.P. State Work Done Well Destruction ❑� Well Diameter Sealing Material (top 501 Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ fNO septic system permitted if'public sewer is available within 200 feet.) Installation will server Residence Commercial— Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth ; SEPTIC TANK ❑II T e/Mf ,I YP 9 Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal ly Distance to nearest: Well Foundation Property Line I. LEACHING LINE I` ❑ No. & Length of lines Total length/size- FILTER BED it E) Distance to nearest: Well Foundation __ Property Line i� SEEPAGE PITS i ❑ Depth' Size Number SUMPS ,I� ❑ 'Distance to nearest: Well Foundation Property-Line _ s DISPOSAL PONDS ! ❑ 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."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 Callfornia.",j! The applicant must call for WI required inspections. Complete drawing on reverse side, Signed X _ IA � _ Title: Date: , I _ R DEPARTMENT USE ONLY t , p i Application Accepted by r Date ! f� � Area ,i Pit or Grout ins ton Date Final Inspection by Date Additional Com nts: ❑ Stk 466-6781 ❑ LOP 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835449", Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box" 2009, Stk., CA 95201FEE r i INFO ' l�AMOUNT DUE AMOUNT REMITTED C H RECEIVED. DATE PERMIT N0 - + EH13-24IREV.1/651 - r 7 O• EH 14-26