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1 APPLICATION FOR PERMIT r SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED z (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 y 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: T 4. Job Address//-/S 7- ro 1r r C) 1r�` 1 c� City Lot Size CiC, PM rt Owner's NameAddress--- a Phone t3 ' �ff yy11.`.„_ . r-�_,,,...,. . :.�T,.... --....,.- _ -„��.,---•�..�..,�, .....-. .r. _ � _ f Contractor'fi1o�l ]`.Cly t ,. AAddress rt� - License No. hone I TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT`❑_ DESTRUCTION 1-1 - -- PUMP INSTALLATION Cl SYSTEM REPAIR ❑ + OTHER ❑ W DISTANCE TO NEAREST: SEPTIC-TANK _SEWER LINES DISPOSAL FLD. PROP. LINE x - -- ' '. 1 A � FOUNDATION � � AGRICULTURE W L OTHER WELL PI /SUMPS INTENDED USE 1 TYPE OF WE PROBLEM AREA CO TRUCTION SPECIFICATIONS EJ Industrial, ❑ Open Bottom❑ Manteca-. -__� of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel,P ck ❑ Tracy ype of Casing Specifications ❑ Public ❑ Other ` ❑ Delta De th of Grout Seal �3 �,sp Type of Grout j -© Irrigation,> prox. Depth ❑"Eastern Surface Seal Installed by i Repair Work Dane ❑ ' Type f Pump H. .; r 5 State Work Done Well Destruction ❑ Well Diameter Sealing Material atop*50'1 1 Depth Filler Material'(Below 50'1 TYPE OF SEPTIC WORK: NEW INSTALLATION O REPAIR/ADDITION DESTRUCTION ❑ (No septic system permitted if public sewer is W Y f available within 200 feet.I Installation will serve: Residence I- Commercial�-At,. Otherr ,tr, Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: t Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ � Method of Disposal Distance to nearest: Well Foundation Property Line 1 ` I LEACHING LINE No. & Length of lines I # .� g Total length/size � +�'"-"-�*--_ :, r FILTER BED ❑ Distance to nearest: Well 460 Foundation _ S' Property Line SEEPAGE PITS ❑ Depth Size J Number SUMPS Distance to nearest: *¢•Well -Foundation Property Line r I DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and'thai%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. `" Ir`- . I , i 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 applican ust calffor all required inspections. Complete drawing on reverse side. t. ; {€Signed X Title: C'nr4ync f Date: w 4 ,O FOR DEPARTMENT USE ONLY I ApplicationrAccepted,bY 4 Date 1 `, 4- Area i r Pit or Grout Inspection by Datef al Insp�on by Date L41— Additional Comments: f; t I ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 b Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE CK*INFO AMOUNT DUE AMOUNT REMITTED f CASH RECEIVED BY DATE PERMIT�NO. ! � 1r �+ EH 13-24(REV. EH 4-29. YW7 37—ti