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:l , a APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT r 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES TYEAR 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 Joaquin Local Health District. Job Address � SURJl4� City + / __ LotSize PM 1 I Owner's Name Address �/ Jr U/1J/,S.y Phone .i I Contractor /-F / f'U_ 1ae__Address 0i �*phone— TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER D DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE L FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS r r INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ;i ❑ Industrial E] Open Bottom ❑ Manteca Ria. of Well Excavation Dia. of Well Casing 1 � r. I ❑ Domestic/Private El Gravel Pack 1:1T'racV` " , e Type of Casin:g'• Specifications i 1 f'l Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout-- I rout__I i Irrigation __._Appiox. Depth l I Eastern Surface Seal Installed by I" tl Repair Work Done ❑ Type of Pump'-,-,_ H.P. State Work Done_ Well Destruction ❑ Well'Diameter Sealing Material (top 501 Depth Filler Material (Below 501 � I TYPE OF SEPTIC WORK: NEW INSTALLATION Cl REPAIR)ADDITION)< DESTRUCTION I 1 iNo septic system permitted if public sewer is :f available within 200 feet.) Installation will serve: Residence Y Commercial_ Other ' Number of living units: --I— Number of bedrooms; �� 1 ... ,` FCharacter of soil to a depth of 3 feet:_"`' '�� r"�.-' Water table depth l SEPTIC TANK ❑- M . .No. Compartments Y/� 6 PKG. TREATMENT PLT. ' '' �^ -;�' r j�"" '� � " Method of Disposal Distance to nearest: U17ell Foundaiibn �C3 t Property Line LEACHINGLINE "'IkI�,yNo._&"L~ength of lines ~a�^ : b"" T �— Total-length/size FILTER'f3Eb> f � Distnce to nearest: Well Foundation `J�' Property Line _6 Q SEEPAGE PITS I 1 Depth Size Number SUMPS 0 Distance to nearest' ':Well s Founclogn Property Line- DISPOSAL PONDS ❑ '� r. , I hereby certify that I have prepared this application and that the WSTk.will be done in accordance with San Joaquin county ordinances, state laws, and f rules and regulations of the San Joaquin Local,Health District.' 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 4 ' 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." _ 3 The applicant must call fora re uired ins 'T ss ( q pections. Complete drawing on reverse t ( Signed X R Titlei- e,4 Date: I MENT USE ONLY' i a Application Accepted by Date ALRa Pit or Grout Inspection by DateFinal Inspection by Date I Additional Comments: : ❑ Stk 466-6781 ❑ Lodi 369-3621 1❑ Manteca 823-7104 Cl Tracy 835-6385 , Applicant - Return all copies tof Environmental Health Permit/Services 1601`x.-?'iaielton Ave," P.O. Box 2009, Stk., CA 95201 FEEr INFO AMOUNT.DUE AMOUNT REKI MITTED -CASH RECEIVED BY DATE PERMIT"NO. + EH 1324(REV.1/n51 " EH 11-26