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a APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA . Telephone (209) 466-6781 I PERMIT EXPIRES TYEAR FROM DATE ISSUED ' (Complete in Triplicate) Application is hereby made totheSan 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.X549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address e 2 City Lot Size - 31 Owner's Name dress �� - Phone)CyAlil Contractor t -A d d r e s /r License Nov �Phone TYPE OF WELL./PUMP: NEW WELL.,0_ WELL. REPLACEMENT DESTRUCTION ❑ PUMP INSTALLATION ❑ �_ �# SYSTEM REPAIR ❑ OTHER. ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. L-PROP. LINE FOUNDATION -AGRICULTURE WELL OTHER WELL ` ,PITS/SUMPS INTENDED USE TYPE OF WELL-J PROBLEM AREA CONSTRUCTION SPECIFICATIONS + t # ❑ Industrial ❑ Open Bottom ;:f ElMarlfeca Dia. of Well Excavation � �k,.Dia: of Weil Casing EIDomesticlPrivate ❑ Gravel Pack=. .. ❑.:Tracy Type of Casing – �5 ecifications c "1 Public ❑ Other i l'Da.'-- Depth of Grout Seal eltType of Grout I I Irrigation —Approx. Depth ''"E I Eastern Surface Seal'lrtstalled by Repair Work Done 0 Type of Pump H.P. State Work Done _ n Well Destruction ❑ Well Diameter ` i Sealing Material (top 501 Depth Filler Material 1661ow 50'1 TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADbMON V DESTRUCTION I I (No septic system permitted if'public sewer is F + available within 200 feet.)~ `Installation will serve: Residence— Commercial_X_Other Number of living units: Number of bedrro/o��om��s, Character of soil to a depth of 3 feet: Water table depth 4444K • SEPTIC TANK ❑ T.ypelMfg� Capacity No. Compartments i r k PKG. TREATMENT PLT. ❑ Method of Disposal Y / Distance to nearest: Well Foundation Property Line �., LEACHING LINE � No. & Length of lines 44 � Total length/size y�. FILTER BED ❑ Distance to nearest: Well Foundation Property Line l SEEPAGE�PITS -__ -)4-Depth Size Numbers – - s r _ SUMPS Cl Distance to nearest: Well{_�4'.f,.._.._< _Fou_n_d_action Property Line DISPOSAL PONDS ❑ 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. 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, 1 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 applicant must call for al quip, ctions. Complete drawing on rev se side. 001/11 Signed X Title: .., ��. _ ^ Date: FOR DEPARTMENT USE ONLY Application Accepted by Date Area AQ Pit or Grout Inspection by Ly / Date Final Inspection by 3 �{ r Date Additional Comments: /44� ❑ Stk 466-6781 ❑ Lodi 369-3 ❑ 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 CK 4 CASH RECEIVED BY INFO DATE PERMIT NO. //�� ryr7 n + EH t7-241REV.:in e1 7 "J ( 1 0/� EH 14-211 L� vi