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APPLICATION FOR PERMIT -• SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 �CJTIv f PERMIT EXPIRES 1'YEAR FROM DATE ISSUED - . (Complete in Triplicate) I. 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 I Local Health District. s r PM Job Address City Lot Size t Owner's Name r P/P4 T dd�s Phone C �r� S Address J ��.,22 License No. Phone Contractor _ TYPE OF WELL/PUMP: 1•NEW WELL, 00 -'� x WELL REPLACEMENT ❑ DESTRUCTION 171fi PUMP INSTALLATION,tV SYSTEM REPAIR ❑ OTHER ❑ /�J DISTANCE TO NEAREST: SEPTIC TANK _._ ��"y SEWER LINES �� DISPOSAL FLD.�+ PROP. LINE M; _. F_0UNDAT,ION_TJ�wAGRICULTU.RE.WELL_ " ._OTHER WELD- MTS/SUMP_S�,q� k INTENDED USE _ TYPE OF WEkL' PROBL' AREA CONSTRUCTION SPECIFICATIONS-", ❑ Industrial ❑ Open Bottom -•.-❑Manteca Dia. of Well Excavation_�Q Dia. of Well Casing Domestic/Private gravel Pack ❑ Tracy� Type of Casing `: Specifications �;ff I-1 Public Cl Other ' F1 Delta Depth of Grout Seal :592 11 Hype of Grout 1V1P.U�ILIRN L�/ I I IrrigationF� 7—��Apprax. Depth '. l I Eastern Surface Seal Installed by Repair Work Doe ❑ Type of Pump -4 H•P• z. I_ State Work Done_ Well Destruction Ll � --Well Diameter 'Sealing-Materiial-((top 501 `! s Depth Filler Materii l,(Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION LI DESTRUCTION Cl,,(No septic system permitted if public sewer is 1 available within 200 feet.) r fir:. Installation will serve: Residence_ Commercial_ Other ,. 4 l Number.-of living units: Number of bedrooms '_..--__ Character of soil to a depth of 3 feet: Y '" �` 'W at6 table depth SEPTIC TANK ❑ Type/Mfg * Capacity � ° Ivo. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line _ + LEACHING LINE ❑ No. & Length of lines Total length/size ' FILTER BED I] Distance to nearest 'Well -Foundation Property Line I SEEPAGE PITS I I Depth Size Number }f SUMPS Ll Distance to nearest: Well `'i-,';Foundation'+ '> Property Line,. ,` '.`.r DISPOSAL PONDS ❑ y - 'r I I hereby certify that I have prepared this application and that the work will be done in accordance with SanrJoaquin county ordinances;:sta`te laws, and rules and regulations of the San Joaquin Local Health District. / F /I : ' ' j 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' i employ any person in such manner as to become subject to workman's compensation laws of California?' Contractor's hiring or sub-contracting signature i certifies the following: "I certify that in the performance of the work for which this permit is issued,d shalla ploy persons subiect_'to workman's cbrnpensa- s _ tion laws of California." The applicant fo all re pectioris.'Complete drawing an re rse s e. Signed X Title: d „Date: FOR DEPARTMENT USE ONLY Application Accepted by Date An Area Pit or Grout inspection by Date Cn Final inspection by Date �` [ Additional Comments: O Stk 466-6781 nLodi 46-3-6211, ❑ 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 FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. INFO Q + EH 13-24 MEV.r i n 5) EH 14.26