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- AP-PLICATION FOR PERMIT – — Y ' SAN JOAQUIN LOCAL. HEALTH DISTRICT "l 1601 E. HAZELTON AVE., STOCKTON, CAEDr Telephone (209) 466-6781 PERMIT EXPIRES 1'YEAR FROM DATE ISSUED h (Complete in Triplicate) Application is hereby made-to the San Joaquin Local Health District for a permit to construct and/or install the work herfnJetrill. Tgagi Patioyis 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 �� '�' '"� g City , Lot Size.go PM L Owner's !Name Address `�.J ��l�f(14er jp Contrac"to " " Address D, [� 710 License No.S z ZG Phone y`�� TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ 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 f-,.:.-,TYPE"OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ' ❑ Industrial U Open Bottom- E Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications M Public Cl Other ❑ Delta Depth of Grout Seal Type of Grout I I Irrigation _.Approx. Depth 1.) Eastern Surface Seal Installed by _ Repair Work Done ='.E77 ,'Type of Pump H.P. State Work Done Well Destruction" Ii, ' "We11Diameter Sealing Material (top 5d'1 '[ pth "ler,Material (Below 50') TYPE OF SEPTIC WORK: `NEW INSTALLATION Ll EPAIR DDITION DESTRUCTION l I (No septic system permitted it public sewer is available within 200 feet.) v ' Installation will serve: Residence_ Commercial� Other I Number of living units: _L_ Numbe"r of a rooms 1°Character of soil to-9 depth of 3 feet: Water table depth Uo SEPTIC TANK O; ,Type/Mfg Capacity" No. Compartments r PKG. TREATMENT PLT..❑.- Method of Disposal Distance to nearest: Well Foundation Property,Lin e " r:. LEACHING`LINE No. & Lengt of linesf 0 Tota! length/size Z FILTER BED - Ir ❑ Distance to nearest: Vl/ell-�3b FoundationQ_ Property Line �S SEEPAGE PITS Depth - Size ;. s Number i SUMPS ❑ Distance to nearest: Well _ Foundation �Dt Property Line S DISPOSAL PONDS ❑ 4-hereby certify that I have prepared this application and that the work will be done in accordance with"San Joaquin-ct irnty ordinances, state laws, and �ules:and regulations of the San Joaquin Local Health District:= l f .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, l shall not ampl�oy.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 ihe'work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." The applicant m call for ail iced spections. Complete drawing on reverse Sid Signed X Title: Date:Is LJ S4 _ — FOR DEPARTMENT USE ONLY Application Accepted by Date Area ar Grout inspection by Date Final Inspection by Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3521 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95291 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH CK RECEIVED BY DATE PERMITNO. +.EH 13-24 iREV. i x 51 '"`�"]� —7/ EH 14-26