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a-f- APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. 'HAZELTON AVE., STOCKTON, CA Telephone.M9) 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 ._8742 N.- Clemt3nt$ Rd, City Li ndp-n Lot Size PM Owner's NameLt? a] �Pl Land.—C;. 7 P Address P-O,ROX 687 TA r den Phone Contractor Puryi Drill ar 1 O Cknse No. 37799.3Phone TYPE OF WELL/PUMP: NEW WELL X] WELL REPLACEMENT ❑ DESTRUCTION G 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 TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Ci Industrial X Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing 16 er ❑ Domestic/Private ❑ ave/ Pack I-] Tracy Type of Casing Specifications o 2 rJ 0 i`1 Public ri Ot r 171Delta Depth of Grout Seal 50 ° Type of Grout JW Irrigation 750 ° prox, Depth t 1 Eastern Surface Seal Installed by Repair Work Done Ll of Pump Tkl'b H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 q Depth Filler Material (Below 50') 'V TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION 1.1 DESTRUCTION f I (No septic system permitted it public sewer is ®r } available within 200 feet.) Installation will serve: Residence_° Comm tial— Other ' `5 Number of living units: Number of bedr ms Character of soil to a depth of 3 feet:. Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: I =- Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ .Distance tti nearest: Welk Foundation Property line SEEPAGE PITS I I Depth Size Number \ �- SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I 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 DrItrict. t 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 Law ia." + The pplicant must II r a requ' din ctions. Complete drawing on r arse side. / Signed Title: Date: { U_SE ONLY 1 Application Accepted byti C Date Area 1 Pit orrou Ins ction b ( ++f I f� Y (( Date � nal Inspection by Date f r Additional Comments: 1 ❑ Stk. 466-6781 1-] Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835 6365 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave.,!P.O. Box 2009, Stk., CA 95201 FEECOUDUE AMOUNT REMITTED CARECEIVED BY DATE PERMIT'INFOEH 13-241REV.+ix5) F_�5w - - d !�°f�EH 14-26 UCJ J ! �47