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APPLICATION FOR PERMIT SAN JOAO,UIWLOCAL 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 LocalHealthDistrict 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 Ryles and Regulations of the San Joaquin Local Health District. yY` ., s .•v," ,. .. , ::, Job Address,2rl�N5,];' 1""y'G`f ilk _ City � Lot'Size. ' "` PM - 1 ` Owner's Name Address'-- Phone _ L C Contractor aw ebZ6 Addressl/77 y 1 dr icense Nog- Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER lam` DISTANCE TO NEAREST:-SEPTIC TANK SEWER LINES 1 s' DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS1SUMPS' "==+ INTENDED USE TYPE OF WELL- PROBLEM AREA CONS71aUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom El Manteca Dia. of W611 Excavation Dia. of Well Casing ,2'Domestic/Private ❑ Gravel Pack ❑ Tracy Type of,Casing Specifications 1l ❑ Public 171 Other [_1 Delta Depth9dffGrout Seal Type of Grout 0 Irrigation ---Approx. Depth ❑ Eastern Surface pSeal Installed by Repair Work Done ❑ Type of PumZI p H.P. s�State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50'1 Depth Filler Material (Below 50') y TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑n DESTRUCTION ❑ (Na septi system permitted if public sewer is i< available within 200 feet.) Installation will serve: Residence_ Commercial_ Other LA Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth �y SEPTIC TANK ❑ Type/Mfg '°Capacity No. Compartments aJ �- PKG. TREATMENT PLT. ❑ j Method of Disposal 9 j Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well +'Foundation " Property Line SEEPAGE PITS ❑ Depth 'Size '^ I Number SUMPS, r __1Distance to nearest: WellFoundation Property Line _ DISP05AL PONDS 1-1 �� ti / _ I hereby certify that 1 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. r Home owner or licensed agent's signature certifies the following: "I certify that in the-perfdrmance 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`15' 's of California." Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work for which this•per„mWit Is issued,-j shall employ persons subject to workman's compensa- tion laws of California." 1 E The applicant m st call for II required inspections. Complete drawing on n Signed X_ -7® Title: Date: �f FOR DEPARTMENT-USE ONLY Application Accepted by �v/_ Date_` Area Pit or Grout inspection by IVIA Date y�inal Inspection by "Date��d. rr Additional Comments: ❑ Stk 466-Ml ❑ 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 ,a. FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT"NO. INFO + EH 13-241REV.1/851 EH 14-26