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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 well/pump and the Rules and Regulations of the San Joaquin Local Health District.ri Job Address 1�4� �• �l�0'y�� s � __ City ��dG' Lot Size S 77C• - PM Owner's Name 1 7w e" Address S9mr Phone �� { � 7�f�,t3•z�o,3 f Contractor fCAddress -r License No.S O KZ/ Phone TYPE OF WELL/PUMP: NEW ELL B-' WELL RE LACEMENT ❑ DESTRUCTION ❑ PUMP.INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK _,%R r� SEWER LINES - DISPOSAL FLD- PROP. LINE FOUNDATION AGRICULTURE WELL -. .OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial " ❑ Open Bottom ❑ Manteca Dia. of Well Excavation /L"� pia. of Well Casing ` 9 Domestic/Private P<Gravel Pack ❑ Tracy Type of Casing G" i�Y'C. Specifications 7 Public ❑ Other a n Delta Depth of Grout Seal l�e� Type of Grout _ fI Irrigation adQ._Approx. Depth I I Eastern Surface Seal Installed by j194A. Repair Work Done ❑ Type of Pump Sc{r(,' H.P. State Work Doone _ I Well Destruction ❑ Well Diameter ! � Sealing Material Itop 5Cpm _ 0') ,./' I Depth 41tv 1/47 Filler Material (Below 50') Pegs . rAr rsvcl TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIR/ADDITION l I DESTRUCTION l I (No septic system permitted if public sewer is t available within 200 feet.) t r Installation will serve: Residence_ Commercial— Other l 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 k PKG. TREATMENT PLT. ❑ ` i- Method of Disposal }� ` Distance to nearest: Well Foundation Property Line LL � LEACHING LINE ❑ No. & Length of lines Total length/size i I� FILTER SED L❑ 'Distarice'to_nearest: Well _ Foundation Property Line �I f SEEPAGE PITS I 1 Depth Size Number SUMPS Cl Distance to nearest: 'Well", Foundation Property Line Q 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 t call for all requir inspections. Complete drawing on reverse side. Signed X Title: Ckr�is.�e. Date: JF c6. FOR DEPARTMENT USE ONLY Q Application Accepted by os. Date 1 Area Pit Grout s ction b -Zr�-3_2b � pe y Date Final Inspection bya Date Ad al Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 923-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 96241 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO EH 13-21(REV.EH 14-28 t i n 55 DS,0 C) Ah