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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1-601 'E, HAZEL i ONV AVE., STOCKTON, CA Telephone (209) 46676781 PERMIT EXPIRES 1 YEARtFROW DATE ISSUED (Complete in Triplicate) iJly.s L. ..;,Yi.�s:§4{r'",}: 1," 10 aZL ' �. ... 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 k made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and the.Ryles and Regulations of the San Joaquin ,Local Health District. b '' rr : �u s� . „Ya w wx ...s.y ; +.jw �✓ ... .` Job Address � �� '[%k A f r�itY Lot Size - PM csC� �1: (,c�,o- Owner's Name - Address r Z phone 6 9 t Contract r Address � [ License No 22 3(CPhone T`- ,I TYPE OF WELL/PUMP: :NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION_ ❑ SYSTEM REPAIR ❑ OTHER El t DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLIT. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS �, t INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ` ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications i ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout z w ❑ Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 r I Depth filer Material (Below 50'1 TYPE OF SEPTICoWORK: NEW INSTALLATION ❑ EPAIR ADDITION DESTRUCTION ❑ (No septic system permitted if public sewer is r J available within 200 feet.) Installation will serve: fResidence Commercial_ Other . Number of living'units:�_ Number bedrooms _ Character of soil to a-depth of 3 feet: Water table depth. S C SEPTIC TANK Type/Mfg CapacityZ600 No. Compartments i PKG. TREATMENT PLT. ❑ _ / t Method of Dig posal Distanceteest: Well Foundation-'�" �Pw . o nearest:— -— � �� Property Line_� } LEACHING LINE IIF No. & Length of lines � Total len"gth/size{ p X t Q � r I r FILTER BED A 13 Distance to nearest: Well Foundation le Property Line 1S SEEPAGE PITS V' `❑ Depth Number o` i r 1 1 SUMPS �Distance to nearest: Well_. � Foundation--,LQ Property Line., DISPOSAL PONDS ❑ hereby certify that I have prepared-this appli' ti'n A 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. ,. ^,;t „. {; Home owner or licensed agent's signature certifies the following: "I certify that-in the performance of.the-work for which this permif,.Is issued, I shall not , employ any person in such manner,as,to-become subject to-workman<s-compensation-laws o`f California 'Contractors hiring or sub-contracting signature certifies the fallowing: "1-certify thatdntthe-performance=of the work for which thissi,ermit is issued fil-shall empicy persons subject to workman's compensa- tion-laws_of-California." c The applicantst caA_for -req red inspections'Complete drawing_on.reverse side Signed R _� {e� �,l i Date: 520 I �`� FOR DEP. RTMENTrUSE-ONLY t� Ap ication Accepted by Date Area ` k or Grout I sn�ection by Date 2:46X�KJ Final Inspection byDate7,e LV d -' Additional Comments: ❑ Stk 466-6781 ❑ Lodi f 369-36621--- 171-Manteca 8237104`' E❑Tracy 835_6365 Applicant- Return all copies to: Environmental Health Permit/Services 116011'E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE r INFO AMOUNT DUE ,. AMOUNT REMITTED CK CASH RECEIVED BY DATE PERMIT'NO. + EH13-24SREV.S/e51 EH 1428