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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR 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 wevpump and the Rules and Regulations of the San Joaquin Local Health District. Job Address ' Cito Lot Size /q APM Owner's NameAn i W f' Address ��-�e� Phone Contractor Z �i Address BOO- 5' 0i �license No..s _Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT DESTRUCTION; PUMP INSTALLAT��I//O}}�N� + SYSTEM REPAIR ❑ OTHER ❑ (0 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS '1N INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS `f� Ll Industria! ❑ Open Bottom ❑ Manteca Dia. of Well Excavif io Dia. of Well Casing 6 R3'Domestic/Private Gravel Pack ❑ Tracy Type of Casing �- Specifications t"1 Public fl Other ❑ Delta Depth of Grout Seal Type of Grout1 . I Irrigation —.-Approx. Depth I i Eastern J Surface Seal Installed by �tS e�r+tff�l>+7� C�� or Repair Work Done 1:1 Type of Pump� _. .-..— H.P. �rL _ State Work Done lamur G�� f Well Destruction Dit Well Diameter Sealing Material Itop 50') Depth Filler Material (Below 50') -- TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR/ADDITION E I DESTRUCTION I I INo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence— Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER SED ❑ Distance to nearest: Well Foundation Property Line r SEEPAGE PITS I 1 Depth Size Number SUMPS ❑ Distance to neatest: Wel! Foundation 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, 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, l shall employ persons subject to workman's compensa- tion laws of California ` The applicant t call for a equir inspections. Complete drawing onn reverse s'de. Q/ J\ Signed X Title: l iaar 1)wu +-� _ Date: FAR DEPARTMENT USE ONLY l Application Accepted by AIJA , Date L �� Area 6 Z� Final Ins action by 1 Date Pit or Grout Inspection by J - Date p Additional Comments: �rl u 7e / ✓%t us g Lt! !l +[ Liv a• �t [L�c v c {� tL xs�i�-yt-f t[s I ❑ 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 2009rS*-- 1 1a 3U r u FEE AMOUNT DUE AMO NT REMITTEDH RECEIVED BY DATE r T. INFO r.EH 13-24(REV. EH 14-26 �! I — ?rSZb 7D