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��\ APPLICATION FOR PERMIT \le,kAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELiON AVE., STOCKTON, CA Telephone {209} 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ;I� (Complete in Triplicate) A ati t\is b y made to the San Joaquin Local Health District for a permit to construct and/of install the work herein described. This application is. mad0 Iii compliance with San' oaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. III'; f Job Address Sa� G✓ ' �14 P-r"2 �i�Y City Ale6 zaz'^ Lot Size PM VA Owner's Name 141 Address �✓� �- 7 - Phone Contractor roc916, Address V-1s L OY License No.4 Phone TYPE OF WELL/PUMP: �` NEW WELL>0 WELL REPLACEMENT L1DESTRUCTION'❑ }:-? PLUMP INSTALLATION ElSYSTEM REPAIR ElOTHER )Q ��n' �~^+�'�} I DISTANCE.TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP.`LINE dig ` FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS r INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing JI ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications f [I Public Q Other F Delta Depth of Grout Seal � Type of Grout j I I Irrigation JI Approx. Depth 17 Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done i 1I w Well Destruction El VIell Diameter Sealing Material Itop 50'1 -4.F0;Fpth Filler Material (Below 50 TYPE OF SEPTIC WORK: NEW INSTALLATION I.] REPAIR/ADDITION { I DESTRUCTION I I (No septic system permitted if public 'sewer is available within 200 feet.i Installation will serve: R lidence_ Commercial___ Other Number of living units: SII Number of bedrooms Character of soil to a depth of 3 feet: �- Water table depth i SEPTIC TANK O Type/Mfg Capacity No. Compartments., I PKG. TREATMENT PLT. ❑ Method of Disposal I Distance to nearest: Well.— Foundation Property Line r LEACHING LINE ❑ No. & Length of lines Total.length/size— FILTER ength/size —FILTER BED ❑ Distance to nearest: Well # Foundation Property Line SEEPAGE PITS I I Depth Size a' _Number SUMPS ❑I Distance to nearest: Well Foundation "` -'Property Line DISPOSAL PONDS ❑i I hereby certify that I have prepared this application and that the work will.be done in-accordance with.San.Joaquin.pounty ordinances, state laws.,.and rules and regulations of thel�San Joaquin Local Health Di%trict. Home owner otAicensed 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." II�' The applica t call forll re uirad 'ns fns. Complete drawing on reverse side. SAN jOAQUIN LOCAL HEALTH DISTRICT ENVIRONMENTAL HEALTH DI �I � Signed X Title: �Prr1A1 !i FOR DEPARTMENT USE ONLY �I Application Accepted by JI�' f Date v Area Pit or Grout Inspection by I Date rY� Final Inspection by Dater � g jAdditional 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 FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT'NO. INFO CASH *.EH 13-24(REV.) x 51 EH 14-26