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�� rt . / APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA ' Telephone (209) 466-6781 NC)to.�/ ' PERMIT EXPIRES TYEAR FROM DATE ISSUED (Complete in Triplicate) 1 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 /6727-0- DiEk ByCity of Size PM r I Owner's Name Address ` Phone Contractor e /LIJ�C�ep Address r �r cense op-7 Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL RLePLACEMENT ❑ .DESTRUCTION ❑ ` PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ I DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS rV I ! 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 } FI Public ❑ Other ❑ Delta _____,"^'^'Depth-of-Grout"Seal_°"' Type of Grout _ •1 ! I Irrigation —.-Approx. Depth I I Eastern Surface Seal Installed by _ Repair Work Done ❑ Type of Pump• H.P. State Work Done I Well Destruction ❑ Well Diameter Sealing Material Itop 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I1 REPAIRIADDITION I_I DESTRUCTION Wo septic system permitted if public sewer is ,� available within 200 feet.)' N Installation will-serve: Residence� Commercial Other 1 Number of living units: Number of bedroom Character of soil to a de th of 3 feet: �. F_ I P Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation' Property Line LEACHING LINE ❑ No. & Length of lines �� - �yT.otal length/size. FILTER BED ❑ Distance to nearest: WelliFoundation '. Property L_'ine` ` t SEEPAGE PITS l I Depth -Size N mbar SUMPS ❑ r Distance to nearest: Well iFoundation Property Line i DISPOSAL PONDS ❑ ....-�- I hereby certify that t 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. I, E 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 subjecf-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." i The applicant must call for al quire inspections. Complete drawing on reverse side. Signed X C. »-,Title:= ,111.7 — Date: FO TMENT USE ONLY } Qty Application Accepted by CLIDate r' `' Area Pit or Grout Inspection by Data Final Inspection by Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 923-7104 ❑ Tracy 635-6385 Applicant—Return all copies to:-Environmental-Health-Permit/-Services-1601-E--HazettonAvet,-P-0:-,Box-2009,-•Stk.-CA 95201--- -.--» INFO AMOUNT DUE AMOUNT REMITTED CA H RECEIVED BY DATE PERMIT NO. + EH 13-241REV.I/H5Y EH 14-28