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APPLICATION FOR PERMIT SAN JOAQU-LN LOCAL HEeLTi DISTRICT j 1601 E. HAZELTON AVE-, STOCKTON, CA PERMIT NO. f -�43 Telephone (209) 466-6781 p DATE ISSUED 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 Joao,uin Local Health District. - Job Address / Q Subdivision Name Owner's Name. Address JQ56 � � L/V-rMnW_ Phone�t Contractor's Name License rf_r License No. Phone TiFE OF WELL%PUMP (JORK: NEW I WELL ❑ WELL REPLACEMENT ❑—DESTRUCTION ❑ s PUMP INSTALLATION N$YSTEM REPAIR , BOTHER, �-_�— -f DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FED. _ PROP, LINE FOUNDATION AGRICULTURE WELL OTHER\WELL PITS/SUMPS 1 1 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS R 17 Industrial. }+� ❑ Open Bottom ❑Manteca Dia. of Well excavation ❑ Domestic/Private Gravel Pack ❑ Tracy Dia. of Well, Casing ❑ Public ❑Other ❑ Delta -TI- ing Lj Irrigation ; Approx. ❑ Eastern Specifications ❑Cathodic Protection , depth _ Depth of Grout Seal ! ❑Geophysical f U Type of Grout Other j Surface Seal-Installed by f Repair Work Done ❑ Ty,pe,of Pump H.P. w PState Work Done Well Destruction ❑ Well Diameter'_ Sealing Material (top'50') j Depth Filler Material (Below 50') ; t TYPE OF SEPTIC WORK: NEW INSTALLATION " REPAIR/ADDITION J (No septic tank or seepage pit permitted if public sewer is t/ available within 200 feet.) ., t installation will serve: Reside1hceCommercial'� Other # ;r,/ it Number of'living units: 1 Number of bed Lot Lot 'size Characterofsoil to a dep 3 ;feet " r-J Water table depth 49 SEPTIC TANK Type/Mfg, -1 -{-.., Capacity No, Compartments PKG. TREATMENT-PLT. ❑ Type/Mfg' �r �`� * CaKc ity*.,—\.�'r�� Method of Disposal SEWAGE SYSTEM f-� Distance to nearest: Well Foundation Property Line DESTRUCTION Q LEACHING LINE A ❑ No. & Length of lines . '�- / > Total length/size } FILTER BED �• Distance to nearest: Well Foundation �, Property Line t SEEPAGE PITS ❑ Depth #. Size Number SUMPS ❑ Distance to nearest: WellFoundation, Property Line DISPOSAL PONDS ❑ � ,. .- 1..,.. _�w .0 I hereby certify that'fI have prepa.redy this�applicaation and that'the`work 'wi11 b'e'done'in 'accordahce'"with Sari Joaquin couhty ordinances,istate 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 shalI'not`,emplroy 6ny person in such manner as to'becom6 subiect'to workman compensation laws of California." t' Contractor's hiring or sub-contracting signature certifies the fofl-owing: "I�certi,fy fhat`in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensation laws of California," I The applicant must c 1 11 r fired inspections. Complete'}drawing on reverse side. 3, Signed X k "Title: Date: f y ## FOR DEPARTMENT USEIONLY_ f Application Accepted by t� ? Area 13 - ❑ Stk 466-6781 Additional Comments: 07 Lodi 369-3621 Pit or Grout Inspection by 1 .,�. Date Manteca 823-7104 F Final Inspection by "` s ' Date Tracy 835-6385 Applicant -Return all copies oh: Environmental HealtPermit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 -FEE—, -,BASE_. - ,RMDUNT DUE _ —AMO..NTREMITTED RECEIVED BY DATE PERMIT NO. INFO D� ...-.10/82.500 EH 13-24 REV. 10/B2 y 1/ 14-26