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o �/ APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 11 r 3J, s 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1YEAR 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 0 I City /� J'] (Lomat Size (J PM Owner's Name C �. Address �� 4Ja� +y / Phone Contractorh4ay— Gam �►� Address rr"'V t /p �-7 a' License Nv Phon 7 7 TYPE OF WELL/PUMP: NEW WELL, f WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION !. SYSTEM REPAIR CJ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP, LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS n � f INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS �� r ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing N XDomestic/Private IXGravel Pack ❑ Tracy Type of Casing 009MC Specifications ('1 Public ❑ Other ❑ Delta Depth of Grout Seal Z- Type of Grou op i I Irrigation '1:- 190-.Approx. Depth Eastern Surf Seal Installed by�� Repair Work Done ❑ Type of Pump + _. H.P. "L ��5566 State Work Done_ Well Destruction ❑ Well Diameter Sealing Material (top 50') r/L'� Depth Filler Material !Below 50') _ C TYPE OF SEPTIC WORK: NEW INSTALLATION t 1 REPAIR/ADDITION l 1 DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence J Commercial_____ Other i I Number of living units: Number of bedrooms � Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ T e/Mf'I i Yp g Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line 1 LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line ul SEEPAGE PITS I I Depth j Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ C 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- 4 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, I shall employ persons subject to workman's compensa- tion laws of California." The applicant must tail or all required inspections. Complete drawing on reverse side. p l Signed X Title: 4:5 Date: — r FOR DEPARTMENT USE ONLY 2/J Application Accepted byDate✓/ Area f Q � Pit or Grout Inspection by Data, t/ Final Inspection by Date Additional Comments: ❑ Sik 466-6781 ❑ Lodi 369-3621 ❑ Manteca 623-7104 ❑ 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 CK INFO CASH RECEIVED BY DATE PERMIT'ND, -EH 14-24IREv,iixsle;1-11— ,t✓2© /1JA ^" M— 747 EH 1426 JcJ .61%y