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Ik}f I APPLICATION FOR PERMIT G SAN JOAQUIN LOCAL :HEALTH DISTRICT 1601 E. Z EL TON 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. f Job Address City ,Lot Size PM I s�i✓,7'a,g$�inc LuauivS P��,4 �E�CI� •vfioi,r Owner's Name A- Address Phone i Contractor's Name /�� k icense No. Phone � TYPE OF WELL/PUMP: NEW WELL Cl' WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER1❑ j DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. � Y 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 Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack L1Tracy Type of Casing Specifications I ❑ Public ❑.Other ❑ Delta Depth of Grout Seal Type of Grout i ❑ Irrigation __4pprox. Depth ❑ Eastern Surface Seal Installed by Repair Work Done❑ Type of Pump H.P. State Work Done 4 (� � Well Destruction 1, •' ❑ -�,We11 Diameter Sealing Meter jai (top 501 ;-Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATIONJ9 REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is <- available within 200 feet.) Installation will serve: Residence_ Commercial_ Other w Number of living units: Number of bedrooms ..` Character of soil�toia�depth of 3 feet:''' L G ' Water t ble depth 0-1 .SEPTICS ANK ' Type/Mfg Capacity l�0 C1 No. Compartments PKG. TREATMENT,P T.''I] f "* ` f~ Method of Disposal r ��•-— :moi- Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size 3 FILTER BEDDi t nce to nearest• - Weil ff M-E Foundation !A4 1f -- Property Line SEEPAGE PITS ❑ Depth - Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 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 must call for all required inspections. Complete drawing on reverse side. Signed X��1.�i -OA2 Title: 2 Date: ,f— 9- IF OR -FOR DEPARTMENT USE ONLY f Application Accepted by-` ur Date (�_g �fZ�,� Area / 1 Pit or Grout Inspection by IY 1IT- Date Final Inspection by_, Additional Comments: ❑ Stk 466-Ml ❑ 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 FEEi (NEO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT"NO. t +EH 1324(REV.10/9:1) .e �� EH 14-28