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C). - AP-P_LICAT-ION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE.T ON AVE., STOCKTON, CA Telephone (209) 466-6781 SQMVEjoPERMIT 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. Thisapplication 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. �1� Q Job Address 3 . rT" O yLot Siz Rc , , *� City a PM Owner's Name f'c1� Address 2 Phone Contractor Address—(?. 4752 Phone?.,. TYPE OF WELL/PUMP: NEW WEL WELL REPLACEMENT Dl STRUCTIO PUMP INSTALLATI N C SYSTEM REPAIfi ❑ OTHER p DISTANCE TO NEAREST: SEPTIC TANK. -/ SEWER LINES DISPOSAL FLD. PROP. LINE - - FOUNDATION AGRICULTURE WELL 30 OTHER WELL PITS/SUMPS�~ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial pen Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing �?r7 ❑ Domestic/Private �0 Gravel Pack ❑ Tracy Type of Casing Specifications "3 F"1 Public , ❑ Other ❑ Delta De th ai Grout Seal '�'�/ -/6 / p Type of Grout _-` ngatian --Approx. Depth f I Eastern Surface Seal Installed by . Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction p Well DiameterkAj Sealing Material(top 50') �V Depth Filler Material,(Below 50 TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR/ADDITION I I DESTRUCTION [ I (No septic system permitted i(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 SEPTIC TANK ❑ Type/Mfg C city No. Compartments PKG. TREATMENT PLT. d Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No.; & Length of lines Total length/size FILTER BED + ❑ Distanoe to nearest: W Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS-,...' ❑ hereby certify that I have prepared,this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, an rules and regulations of the San Joaquin Local Health District. Home owner or licensed agent's signat6re certifies the following: "I certify that in the performance of the work for which this permit is issued, I sld employ any person in such manner as-to become subject to workman's compensation laws of California."Contractors 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 mu for d ins pe S. Complete drawing on reverse side. Signed X Title: Date: FOR DEPARTMENT USE ONLY 77 Application Accepted by Date S% � Area r& Pit or ro t Inspection by Date Final Inspection by 1 Date Additional Comments: ❑ 5tk 466-081 L1 Lodi 369-3621 p anteca 823-7104g Tracy 835-6385 Applicant- Re6n all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE' AMOUNT REMITTED CIC RECEIVED t3Y7 INFO CASH '•DATE PERfi11T'NO, +.EH 1324(HEV.I/H 5) [ vv ty�a EH 14.28 �` ! i C, l