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APPLICATION O PERMIT SAN JOAQUIN LOCAL'HEALTH DISTRICT 1601 E.' HAZELTON AVE.,.-STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1. YEAH FROM DATE ISSUED i I (Complete in Triplicate) Application is herehy 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. 18&2 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. c � Job Address �1(2 ef 0-fr7u7-R—V City i4GaN Lot Size PM Owner's Name Ey<-�ok'An-o7-& Address - .._ !q-GPhone Contractor s /4 . [ z %E? Address. �IY9Mi✓�/ iq License No. ?�5 Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ + t PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ K DISTANCE TO NEAREST:.SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE ! 6 i FOUNDATION AGRICULTURE WELL" OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia, of Well Casing 11 DomesticEPrivate - ❑ Gravel Pack ❑ Tracy Type of Casng-"`"' •f'' w Specifications + 1-1 Public C7 Other C] Delta Depth of Grout Seal Type of Grout i f I Irrigation -Approx. Depth I 1 Eastern-- Surface Seal Installed by Repair Work'Done ❑ Type of Pump H.P. State Work Dane_ Well Destruction ❑ Well Diameter, Sealing Material(top 50') Depth ` Filler Material {Below 50') - ; TYPE OF SEPTIC WORK: NEW INSTALLATIONn' O.RFPAIR/ADDITION l I DESTRUCTION i I (No septic system permitted if public sewer is available within 200 feet.) Installatiowill servei Residence,� Com^� r mercial Other i --t Number of living units: / -- Number of bedrooms� 4 i 1 Character of sa to a depth of 3;feet: ` G Water table depth s SEPTIC TANK ❑ Type'/Mfg Capacity_ Z ! _ No. Compartments s C PKG. TREATMENT PLT. ❑ ' I�- �Y; �- Method of Disposal Distance to nearest:. Well Foundation OAU Property Line LEACHING LINE A No. & Length of lines PT Total length/size e9 �T FILTER BED ❑. 'Distance to nearest:< JWell /oF' Foundation Property Liner i SEEPAGE PITS n Depth 7- Size 1 Number -SUMPS L7 Distance to nearest:9,.:......Welf .t Foundation /34)` `'property Line�`-F7- E DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and,tf�atShe.work will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the SaWJoaquih Lpcal-Health p sfrict .�.. f Home owneF or licensed agent's signature certifies the following:"I certify, that in h'peiformance of the work for which this permit is issued, t 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 Derr o(fis subject to workmari's.compensa- ? tion laws of California. The applicant must call.for 0 requir d inspections.-Complete dravring•on reverse side. ' Signed XI r + Title: _ 1t _ f Date: OR DEPARTMENT USE ONLY tr ! Application Accepted by f Date Air rea M41 Pit or Grout;Inspection byr 'k Date :. . al Inspection by Date Additional Comments: ❑ Stk 466=6781 LI 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, Sik., CA 55201 1-. 1 r. FEE AMOUNT-CLUE.. -+.-.-AMQtiNT REMITTE[]^ r.CK. - __ s CASH RECEIVED'Bl ^'}]ATE _ PERMIT NO. +.EH 3-24(REV, EH 14-28 Y �/'