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APPLICATION FOR PERMIT P SAN JOAQUIN LOCAL HEALTH DISTRICT A1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete its 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 wellipump and the Rules and Regulations of the San Joaquin Local Health District. 2 1 Job Address V✓Z L U. "City Lot Size PM Owner's Name ` 6 _ Address 30r• __.._.. t Phone Contract Address , r � _7 6 License No724/Z_7—�' Phone 3 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION 0 ob PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER E3DISTA_ _NCE�TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE I FOUNDATION AGRICULTURE WELL OTHER-WELL PITS/SUMPS INTENDED USE _ TYPE OF WELL _PROBLEM AREA CONSTRUCTION SP!CIFICATIONS _ i ❑Industrial y❑ Open Bottom ❑ Manteca Dia. of Well Excavation._ r ~Dia. of Well Casing I t ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing = Specifications 11 Public Cl Other ❑ Delta Depth of Grout Seal� Type of Grout _ I I Irrigation _.-Approx. Depth I i Eastern Surface Seal Installedftiy Repair Work Done ❑ Type of Pump H.P. State Work Done_ 1 Well Destruction ❑ Well Diameter Sealing Material (top 50') C Depth Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTAL ION IEPMR/ DDITION' DESTRUCTION'I 1 INo septics stem permitted if " y p public sewer is available within 200 feet.) Installation will serve: Residence 1 Commercial " Qi +r_. r $ � . Number of living units: � Number of oms r 4 Character of soil to a depth of 3 feet: A �'`-t Water table depth 0 SEPTIC TANK Type/Mfg Capacity No. Compartments a PKG. TREATMENT PLT. 0 Method of Dispgsal Distance to nearest: Well Foundation' �} r .'g � 1?d Property Line J ' LEACHING LINE No. & Length of lines r T.pl length/size FILTER BED ❑ Distance to nearest: Well Q Foundation _/0 Property Line SEEPAGE PITS Depth J�'�h Size moi' Number SUMPS L� Distance to nearest:,.J_Well _P�Foundatiorr ". � Property Line - DISPOSAL PONDS ❑ f I hereby certify that I have prepared this application and that the work wF11 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." G r� The applicant musc I fora � rn oplete drawing..on reverse Id t Signed Tltle: t v Date: e A, 0 C3 FOR DEPARTMENT USE ONLY 11 _C Application Accepted by _ r, Date 1 "[J Area i� Pit Grout inspection by Date 1 Gt- l4 t F in Inspection by Dat Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 C3 Manteca 823-7104 ❑Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601,E,)Hiz61tori Ave„ P.O. Box 2009, Stk., CA 95201 INFO FEE �AMOUNTEAMOUNTREMIIITED �SH-� � AECEIVED BY DATE PERMIT'NO. EH 13-21[REY.r i K sf i r