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1�1 APPLICATION FOR PERMIT 1"will' SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 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 City Lot Size S,Ac pry Owners Name Addresses � Phone -C/ 95 Contract AddresLicense Ngflff"_ —Phoneh TYPE OF WELL/PUMP: 1 NEW WELL X' WELL REPLACEMENT ❑ DESTRUCTION ❑ r. PUMP INSTALLATION SYSTEM REPAIR ❑ ,OTHERf❑ n DISTANCE TO NEAREST: SEPTIC TANK 106 SEWER LINES IBD DISPOSAL FLO.115 0 PROP. LINE iz Q FOUNDATION 30 AGRICULTURE WELL OTHER WELL PITS/SUMPS r INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial Open Bottom El Manteca Dia. of Well Excavation Dia. of Well Casing ADomestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing � Specifications 12— FI 2FI Public ❑ Other ❑ Delta Depth of Grout Seal •�� E Type of Grout�f ,A� Cc'�WErT i'SaYd_ I I Irrigation —Approx. Depth 1 I Eastern Surface Seal Installed by 1110nSC dt4111? z v_a _ Repair Work Done ❑ Type of Pump Sub H.P. 2. State Work Done_ r Well Destruction ❑ Well Diameter Sealing Material Itop 501 Depth Filler Material (Below 50'1 — TYPE OF SEPTIC WORK: NEW INSTALLATION I-I REPAIR/ADDITION I 1 DESTRUCTION I 1 INo septic system permitted if public sewer is available within 200 feet.) r 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 q ` _ SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments �V PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line 6. LEACHING LINE ❑ No. 8 Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line t. SEEPAGE PITS I I Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line 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. "I certify that in the performance of the work for which this permit is issued, 1 shall not Home owner or licensed agent's signature certifies the following: 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 applican ustr all f r al ,equired ' sspections. Complete drawing on reverse side. Signed X /. Title: (2!' 4"h,7 1'--ro-2- Date: LO,[��CY,T FOR DEPARTMENT USE ONLY Application Accepted by T Q yppp, /�/^/,y _ Date d`�� A�—T—�-- Pit or ro t Inspection by- /�.4>� v "Y� ate—Final Inspection by ��, Date Additional Comments: 666 - /I ❑ Stk 466-6761 ❑ Lodi 369-3621 ❑ 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 95201 AMOUNT DUE AMOUNT REMITTED CASHRECEIVED BV DATE M[FEE rEH 1124 IREV.1/x51 3QU1 EH 11-26 .sr _ 11 —7nC1' P