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i f APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON,AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES TYEAR 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. Job Address / V 6 V_,�/��s?�v /L,G[. City Lot Siie / _ PM Owner's Name Address /Soyf Phone' -�7 Dv Contract Address fE< t� License No. -Z:202 w Phan ; �� TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ F I AA PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ k'f DISTANCE TO NEAREST--SEPTIC.TAN SEWER LINES .Y. DISPOSAL FLD. PROP. LINE FOUND`A'TION. -.. AGRICULTURE WELL `OTHER-WELL PITS/SUMPS INTENDED USE —TY-PE OF WELL PROBLEM AREA.�CONSTRUCTION.SPECIFICATIONS Ql 17) Industrial ❑ Open Bottom 11 Manteca Dia. of Well Excavation Dia. of Well Casings ` ❑ Domestic/Private ❑Gravel Paces ❑ Trac ,t�� Type of Casing Specifications ; M Public F1-Other-` �., ('l:D"ecce Depth of Grout Seal Type of Grout Irrigation A _ I I �� I ' w t .- pprdx. -Depth-"I Eastern astern Surface Seal Installed by Repair Work Done ❑ Type bf Pump_ H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material atop 50') t Depth` ' Filler Material (Below 50r) TYPE Of SEPTIC WORK: NEW-INSTALLATION K REPAIRi-ADDITION..[..].._.DESTRL'1CTI0_N_I'-C-(No.septic.system permitted if public sewer is f I� available within 200 feet.► Installation will serve: Residence- Commercial_#Other Number of living units: ; Number-of_ Broom Character of soil to a depth of 3 feet! Water table depth SEPTIC TANK X Type/Mfg rCapacity No. Compartments PKG. TREATMENT PLT.-13— --,—_`y Method of Disposal- , Distance to nearest: Well« Foundation ,(� Property line_� I LEACHING LINE No.l&.Lbngth of lines "' Q Total length/size x ' FILTER BED ' .Distan a to dearest: .f Well-+.z�� Foundation /f3 Property Line I SEEPAGE PITS CI Depih, r ! Size ^N'umber SUMPS Distance to nearest: Well / Foundation Property Line DISPOSAL_PONDS ❑ hereby certify that 1•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'Healtfi'Di"M iEl. r Home owner or licensed-a ent's-agent's nature-certifies the following:e g g: "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 mus c fpr all re uire i pections. Complete drawing on reverse side/) .. Signed Title: Date:.. ✓� FOR DEPARTMENT USE ONLY Ap ication Accepted by Date Area Z or Gro tflnspection by ate Final Inspection by / "' /,<L DateFJ Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 623-7104 ❑ 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 DUCE AMOUNT REMITTED CASH CK RECEIVED BY DATE PERMIT'N0. +,EH 13-24(REV.r/x 51 EH 14-28