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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 I PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is he+eby 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 welUpump and the Rules and Regulations of the San Joaquin Local Health District. t , Job Address 1`^'111 J City Lot Size PM Owner's Name Wss Phone ` Contrct ao��'�t- _ Address 350 ___ w' _"License No. Phone_/ _ _ -.- TYPE OF WELL/PUMP: NEW WELL LJWELL REPLACEMENT El DESTRUCTION ❑ t PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE I FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS J1 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom. f Manteca ---Dia-of Well-Excavation--- -�-Dia-of-Well Casirng�- f ❑ Domestic/Private ❑ Specifications Pack� ❑ Tracy Type of Casing P I Cl Delta Depth of Grout Seal Type of Grout FI Public fl Other t r I I Irrigation x'_Approx. D6p.th.'. 'I'I Eastern Surface Seal Installed-ay Repair Work Done ❑ Type of Pump r. H.P. State Work Done Well Destruction ❑ Weil Diameter i Sealing Material (top 501 ` Depth + -- YlFiller-Material iBelow 501 TYPE OF SEPTIC WORK: NEW INSTALLATION t t=AWAIRVADDITION 1 I DESTRUCTION l I (No septic system permitted if public sewer is V i 1 available within 200 feet.I Installation will serve: Residence Commercial— Other Number of living units: _/__ `Number.of bedrooms r oms1� __1 Character of soil to a depth of 3 feet: r ,....� Water table depth SEPTIC TANK IST,/Mfg �` ee . �apacity—smL No. Compartments '� f PKG. TREATMENT PLT. ❑ D�`, C�(��_ tJl p&Ee- .clk� Method of is osal Distance to nearest: Well Foun tion J -Property Line LEACHING LINE Ll No. & Length of lines I Total length/size FILTER BED ❑ Distance to nearest: Well Foundation ' Property Line SEEPAGE PITS I I Depth Size _ Ngmher01 SUMPS istance to nyarest:°- Well w-^�--�"°�"-Foundation_j._C�! Property Line DISPOSAL PONDS ❑ r 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. 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 beco 'e subject to workman's compensation laws of California Contractor's hiring or sub-contracting signature e any arson in such manner as'to m 1 P y p subject to workman's com ansa-g certifies following: "I certify that in the performance of the work for which this permit is issued, I shall employ personsP tion lawsof fornia." The applicant mus all for I egtai dins C m tete dr ng-on reverse side. r j da Sign Titl :' te: t FOR DEPARTMENT USE ONLY A Application Accepted by Date Ratoeat Inspection 4 v �"""�`� Data FS Final Inspect o by 7Ff7��- Date Additional Comments: ❑ Stk 466-6781 fl Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Bax 2009, Stk., CA 95201 _F.EE AMDUNT DUE ' AMOUNT'REMITTEO'. _ CK" RECEIVED BY - DATE Y PERMIT'NO. INFO CASH t +.EH13-24 thEV.l i M 51 / —1 1 1 0 EH 14-26