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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL.HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA --Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED p , (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 well/.pump and the Rules and Regulations of the San Joaquin Local Health District..`" f xCity otJob Size I�' PM Owner's Name UA*J '6Z-06Address �7-a-774 S f='I2 DF2i UC Phone 9 — ContractorlU*S Address -i6 S-t License No. Phone ^3 Y TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ... --SYSTEM R PAIR ❑ .�� .x OTHE ❑ r DISTANCE TO NEAREST: SEPTIC TANK ,SEWER LINES �7f pISPOSAL FLD.J �� r PROP. LINE FOUNDATION Ioc� AGRICULTURE WELL --- OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS t-- F1 r❑ Industrial ❑ Open'Bottom ❑ Manteca Dia. of Well Excavation !` Dia. of Well Casing ,Domestic/Private CR"Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta " Depth of Grout Seal ' Type of Grout ❑ Irrigation r f_2.OAppiox4Deppth }ElEastern r s Surface Seal Installed by Repair Work Oona Cl Type of Pump, sub H.P. 1 YZ- State Work Done YINS�Act f1� Well Destruction ❑ Well Diameter Sealing Material (top 501 14 1 Depth ` Filler Material (Below 501 s TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is f available within 200 feet.) Installation will serve: Residence Commercial_ Other Number of living units: Number of bedrooms I Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK . ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ J Method of Disposal Distance to nearest: Well Foundation Property Line t LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: �' Well" '"` Foundatiorix _ Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well 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,I shall employ persons subject to workman's compensa- tion laws of California." The applicant must call foir all required inspections.' Complete drawing on reverse side. Signed X A f 1 A f!oma a, w Title: �t ,A 7 _ Date: l a 2.7 -sin FOR DEPARTMENT USE ONLY Application Accepted b Date 'Z?—o Area � ' Q Pit or Grout InspectioIA Date Final Inspection by v Dat,/,,2— Additional 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 INFO AMOUNT DUE AMOUNT REMITTED CXSFT CK //RECEIVED BY DATE PERMIT N0. EH 13-24(REV.1/851 G.` 1,0`� EH 1426