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Y ¢ . APPLICATIONFOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA G Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE 'ISSUED 'i (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 l` ff2 " -� City Lot Sizea�� S PM 5'ae Phone` 1 22 . Owner's Name Address __ Contractor f ¢Addi ss76 l .r -/ 13 - °License Nq�� Phone JOV- _TYPE OF WELL/PUMP: NEW WELL-:CJ 'WELL REPLACEMENT E_] '_ DESTRUCTION ❑ PUMP INSTALLATION ❑ "-SYSTEM REPAIR ❑ r. OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES ' DISPOSAL FLD. PROP. LINE Y(r FOUNDATION""" .AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL. PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom�.t; ❑ Manteca Dia. of Well Excavatio`'nr Dia. of Well Casing C>1 ❑ Domestic/Private ❑ Gravel Pack ► E Tracy Type of Casing Specifications } 17 Public F1 Other � f F7 Delta Depth of-Grout Seal Type of Grout _ 11 Irrigation _.Approx. Depth I I Eastsrn -Surface Seal Installed by _ Repair Work Done LIType of Pump """`°" '" H.Pi� �"' State Work Done [ Well Destruction ❑ Well Diameter Sealing Maternerr a! (top 50') Depth I Filler Materiah.(8616w 50') TYPE OF SEPTIC WORK: NEW INSTAL ION I 1 REPAIR/ADDITION . .DESTRUCTION ( I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial'_ Other' Number of living units: Number o_ x f bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK Type/Mfg �Capacity� " " Y No. Compartments ti. PKG. TREATMENT PLT. ❑ �, 9 1Method of.Dis al t 1 Distance to nearest: Well Foundation 4Property- � ert Line P Y _ 4 - j LEACHING LINE No. & Length of tines _ Total length/size FI ER BED El Distance Ito nearest: ell- Foundation �� Property Line SEEPAGE PITS i I Depth19-7F-��•-5 + ?Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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 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." i The applicant must ca I o all raquired pections. omplete drawing on revers side. Signed X Title: Date: 0// c- ,-FOR DEPARTMENT USE ONLY Application Accepted byJ Data A2-13-004c- Area Pit or Grout Inspection by Date Final I tion b Date Additional Comments:_ ❑ Stk 466-6781 ❑ Lodi 369-3621 El Manteca -7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Envirolnmental Health Permit/Semites 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201FEE INFO �AMOUNT DUE AMOUNT REMITTED CA H RECEIVED BY DATE PERMIT'NO. * EH 13-241REV.riga) /dS o� ��- EH 14-26 . - C/