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e DO r� _ APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 t PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ;I (Complete in Triplicate) Application is heiaby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described!THs application is I 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 d, 3 ca _ E/1 Esu k/=rE City Lot Size Owner's Name i_ l ) E r 1 .r-- r -Address Phone - Contractor \NPtL.JPtLL--CnW 5t Address CUN4kt4censeNo. 30Phone -5 ,1 TYPE OF WELL/PUMP..: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Y PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK i SEWER LINES DISPOSAL FLD. PROP. LINE r FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDEDyUSE TYPE OF WELL' PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial' ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by " Repair Work Done ❑ Type of Pump I H.P. State Work Done r Well Destruction ❑ Well Diameter ' Sealing Material (top 50') `..Depth,. _ -___ - Filler Material (Below 501 TYPE OF SEPTIC WORK: NEWINSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION o septic system permitted if public sewer is / available within 200 feet.) Tz Installation will s rv4 Residence Commercial_ Other Number of living units: —17,--4 umber of bedrooms Character of soil to a depth of 3 feet: -- - Water table depth i SEPTIC TANK C1Type/Mfg I� Capacity No. Compartments PKG. TREATMENT PLT. ❑ i Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑r-No' &Length of lines Total length/size. FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth __size ' ` Number SUMPS ❑ Distance to nearest: Well Foundation—'Property Line T. DISPOSAL PONDS ❑; r 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. l 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 C lifornia.,.f fr The applicant �caallor "II req ired pecti n plate drawing on reverse side. } Signed Title: Date: i FOR DEPARTMENT USE ONLY —App licat n Accepted by - - - M Data �� Area Pit or Grout inspection by Date Final Inspection by Date Additional Comments: r ❑ Stk 466-6781 ❑ Lodi 349_36210_ anteca_823m7.104 Tracy-835-6385 Applicant Return all copies to: Environmental Health.Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEECINFO AMOUNT DUE. AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. + EH 13-24 SFtEv. { EH 14-26 Y