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o ' APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE 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 Ryles and Regulations of the San Joaquin Local Health District. Job Address (j) City Lot Size PM % Owner's Name Y. I�, ��_�, Address �1 40 lAJ• ��tL 0 77 !.0 ,f Phone Contracto ��i�u� Address .'Licehse No.��Phone lL TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLAOEMENTEl r DESTRUCTION L1� r , PUMP INSTALLATION ❑ __ SYSTEM,REPAIR_i7-,;�_; OT_yEii,ET— DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES Z, DISPOSAL FLD. PROP. LINE `FOUNDATION AGRICULTURE WELL .OTHEA.VI]EL'L PITS/SUMPS INTENDED USE* TYPE'O. F"UUELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial r rY1 pen.,Bottom ❑ Manteca pia. of Well Excavation t Dia. f 1�Vell Casing ' ❑ Domestic/Private U Gravel Pack ❑ Trac 1 Type of Casing g Y f YP 9 ,' � Specifitbns .- ❑ Public ❑ Other ❑ Delta I Depth of Grout Seal' - Type of Grouts y ❑ Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed-by Repair Work Done ❑ Type of Pump 111 H.P. State Work Done Well Destruction L1, Well Diameter Sealing Material (top 50') Depth, ' ! Filler Material (Below 50'1 , TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ 'REPAIR/ADDITION ❑ DESTRUCTION (No septic system per fitted if'public sewer is Z available within 200 feet.) Installation will serve: Residence— Commercial��Other ' i Number of living units: Number of bedrooms ! Character of soil to a depth of 3 feet: j Water table depth I SEPTIC TANK ❑ Type/Mfg I I Ca city l No'Compartments i PKG. TREATMENT PLT. ❑ h } i �'�(,..! ,��.. i Method of Disposal Distance to nearest: Well , Foundation c Property Line + LEACHING LINE & No. & Length of lines i l:'t Total length/size~ FILTER BED ❑,. Distance to nearest: Well 's Foundation Property Line SEEPAGE PITS 91"DepthSize Number 9 SUMPS i'N01 Distance to nearest: ;Well JFoundation Property Line DISPOSAL PONDS d; I hereby certify that I have p repared 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: "l certify that in the performanc6 of the work for which this permit is issued, I shall not employ any person in suc manner as to become subject to workman's compensation laws of CgNrnia."Contractor's hiring or sub-yontracting signature certifies the following: " certify that in the perfor nce bf the work for which this permit is issueM,ylxshall employ persons subject to workman's compensa- tion laws of Calif mi The ap lica u II for all require ctions. omplete drawing,q re side. i9n Tit7e r Date: FOR DEPAR4`MENT USE ONLY �j Application Accepted bye Date ✓ 1 Areapp�� ii r V� Pit or Grout Inspection by E Date_1 Final Inspectio y Date C 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 I 1 FEE AMOUNT DUE AMOUNJ REMITTED CASH RECEIVED BY DATE nPEERMIT"NO. + EH13-24(REV.I/a 5) �� ~ r✓t�j.• !1'l-'Z5 EH 11426