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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON 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'Y" ` �< City CQ Lot Size a PM Owner's Name �Ltik�rC ! ewlj 4` Address Phone O 9 O Contractor {/u� �/!! y w Address_ _ -J�F-� License Na. ��a6� Phone 3-7-711 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 S 7 PITS/SUMPS ^� INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATION C1 Industrial ❑ Open Bottom 1-1 Manteca Dia. of Wel! Excavation 16 Dia. of Well Casing WD/o� stic/Private `Gravel Pack ❑ Tracy Type of Casing �'r >��L d 167 Specifications f l P[rblic h��✓!7 F) Other ❑ Delta Depth of Grout Seal 7-0 Type of Grout % I I Irrigation Ava!Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material Stop 501 Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION i 1 REPAIR/ADDITION I I DESTRUCTION l I (No septic system permitted if 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 Capacity No. Compartments PKG. TREATMENT PLT. ❑ .N Method of Disposal �� r istance to nearest: Well Foundation Property Line Q' LEACHING LINE Ga ❑ No. & Length of lines Total length/size FILTER BED ��,(#�❑ Distance to nearest: Well Foundation Property Line 1 SEEPAGE PITS I I Depth Size Number SUMPS 0 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 Di1trict. 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, 1 shall employ persons subject to workman's compensa- tion laws of California." The applicant m call far II req red inspections. Complete drawing on reverse side. Signed X Title: r n�ivl / �j flz ate: Q EPARTfNENT USE ONLY r-A Appli ccepted by _ Dated — TJ� Area Pit or (11Y spection by �7c��_ Date .Z�f�� Final Inspection by Q-�±S2ay_ y`� Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Mente 823-7104 ❑ Tracy 835-6385 Applicant- Return all co es to: iro mental Health Permit/Services 1601 E. Hazelton Ave., P.O. 2009, Stk., CA 95201 L� -SmQZ ( /2-7/6' i FU INFO MOUNT DUE AMOUNT REMITTED I C SH RECEIVED BY / DATE PERMIT'NO. +.EH 14-24(REV.l�w 51 1-7010 ' � � // 7 fr�i