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f w- 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 Rules and Regulations of the San Joaquin Local Health District. Job Address t ... o�� City Lot Size PM �C {� 4 Owner's Name � Address _ Phone �i _ ,,5(-D . .`T)" Y -L-icense-No.- -3 - •Phone--- _&X," "CantiactorT� Li� Addresses TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE _ FOUNDATION_ AGRICULTURE WELL QTHER WELL PITSISUMPS INTENDED USE _ TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom Cl Manteca - Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing—., Specifications N 1-1 Public r l Other f} Delta Depth of Grout Seal Type of Grout I Irrigation Approx. Depth I 1 Eastern Surface Seal Installed by Repair Work Done-r❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material Itop 50'I p !� Depth Filler Material (Below 50') �V TYPE OF SEPTIC WORK: NEW INSTALLATION i AIR/ADDITION i I DESTRUCTION I 1 INo septic system permitted if public sewer is- �{ available within 200 feet.I r Installation will serve: Res i ence},�Commercial Oqr - Number of living units: Number of bedroom_41- s #, ti e-,y -r Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK kW-vpe/MfgC6 . 'C.h'YZCapaciCompartments. PKG. TREATMENT PLT. ❑ Method of Disposal l M Distance to near st: Well Foundation Property Line LEACHING LINE Length of lines a Total length/size l r 'FILTER BED ❑ Distance to nearest Well Foundation_-__:.. � Property Line ,-. ' SEEPAGE PITS 4�L�epth Size:.60 Number i SUMPS < r ❑ Distance to nearest .�"Well Foundation — Property Line e1 ®` DISPOSAL PONDS D ' 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 ofpework for w_i i!c this permit is issued, I hall employ persons subject to workman's compensa- tion la alifornia ' -' The applicant for at eq 'ad pectic s. a drawing on re se si { de. r Signed I Title: Date: dl FO EPAPIMENT USE ONLY k Application Accepted by rlo Date ��"�`r'-5-7 Area Datr��9 .f7 Oil Grout Inspection b 0 �oat�o �-a r Final_Inspection by_` Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 CC] Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton"Ave., P.O. Box 2009, Stk., CA 95201 FEEAMOUNT DUE AMOUNT REMITTED' CAK H RECEIVED BY DATE PERMIT'NO. INFO a EH 3.24 IRE 4-26 EH t4-26 'r!