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APPLICATION FOR PERMIT ,,_ Yrs — SAN JOAQUIN LOCAL HEALTH DISTRICT , 1601 b H HAZEL-1:6 'VE_ STOCKTON, CA ®r, • � I JN Telephone.(209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Z) p (Complete in Triplicate) ENVIRO. iENT��A��L��/IHEALTH Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work hkrEi WhT/b'ett,P4A9 lication is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 fot well/pump and the Rules and Regulations of the San Joaquin Local Health District. /mayIA,A Job Address �LJ _V Kr! l�D✓Q. tl Cit of Size. PM `� 4SZa"T Owner' Name Flo V'�3yt ems' �i Q�Cdb� , �• Phone to Q Contractor U-0 'JC [ 7-License No. bl 31 Phone_ v C7 !: TYPE OF WELL/PUMP: NEW W LL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF:WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS t❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing r ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications 17 Public Ll Other F1 Delta Depth of Grout Seal Type of Grout 9 _ r _I I Irrigation _.Approx; Dept Irl Y Eastern Surface Seal Installed b _ ff a r , jam-Repair.Work Done W Type of Pump -2L1--bH.P. 1 State Work Done_ t s Well Destruction ❑ Well Diameter Sealing Material (top 50') *i Depth "I Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR/ADDITION I I DESTRUCTION I i INo septic system permitted if public sewer is I-Ai (" ° t available within 200 feet.] / LL Installation will serve: Resicl6ce'SLI Corpmercial' Other 1 t✓� •A--i�I ! .t t t� 1 Number of living units: Number of bedroarns __w Character of soil to a depth of 3 feet: Water table depth i SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments, I_JPKG. TREATMENT PLT. ❑ r Method ofdisposal 4 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 r SEEPAGE PITS f I Depth 'f Size Number SUMPS ❑ Distance to nearest: Well Foundation Property tine DISPOSAL PONDS ❑ 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 regula ' the San Joaquin Local Health District. Home own r licensed ent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not employ a person in suc manner as o becom ect to workman's compensation laws of California Contractor's hiring or sub contracting signature certifies he following: "I rtify that i t e ma ce of the work for whichothiermit is issued, I shall employ parsons subject to workman's compensation la s of Cali rnia 'The a `plican ca or all e e drawing o rei Signed Title: Rate: 4 ' DEPAR ENT USE ONLY 1 Application Accepted by _ J�� -v Date Area i Pit or Grout Inspection by Date final Inspection by Date 4 ` Additional Comments: ❑ Stk 466-6781 ❑ 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 INFO FEE AMOUNT.DUE.1 AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. �.EH 13.24(REV,r i n 5) EH 141_w