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0 APPLICATION FOR PERMIT 2- ' SAN JOAOUIN LOCAL.,HEALTH .HEALTH"DISTRICT Fa` p�vt 1601 E. HAZEL T ON.AVE.,.STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES I YEAR.FROM DATE ISSUED {Complete in Triplicate) 3 Application is heieby 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 Jbaquin Local Health District.' Job Address i City Lot Size. Owner's Name ' yt�L]1 Address i Phone Contractor U� ddress�C,L� C_]l �1 )�L'icense No. Phone` TYPE OF WELL/PUMP: NEW WELL WELL`REPLACEMENT ❑ DESTRUCTION.❑ PUMP INSTALLATION.4 ! '.� SYSTEM"''REPAIR ❑ OTHER-❑ ,c . DISTANCE TO NEAREST: SEPTIC TANK _ SEWER LIN�S�- l _DISPOSAL_F..Lq.---- ROP . LI N E .. `FOUNDATION Y AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE i TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS # ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of.Wekl Excavation. - Dia. o;f Well.Casing ' ❑ Domestic/Private 0 Gravel Pack ❑ Tracy Type of Casing SpeciTcations ; ❑ Public ❑ Other J'❑ Delta Depth of Grout Seal Type of Grobt a '•• �"' ❑ Irrigation I_Approx.``Depihr--❑ Eastern Surface Seal installed by ( j Repair Work Done .❑ Type of Pump s �t�.� H.P. State Work Done Well Destruction , ❑ Well Diameter,,. ` +.� .? Sealing Material Itop 50 Depth v Filler Material I Below 50 TYPE OF SEPTIC•WORK: (NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION 0_(No septic system permitted if,public sewer is available.within 200 feet.) ' i Installation will serue: Residence_ Commercial i Other , Number of living units: f 1 Number of bedrooms ! 4 r .. F Character of sorl to`a depth df:3 feet: - -- --1 -- - - =r V1la2er table depth —+ SEPTIC TANK k ❑� Type/Mfg �1 Capacity No. Corripaitmehts �PKG..TREATMENT`PLT:,❑! Method <f isposal x Distance to_nea:rest.._..,.-.Well_----.--- -Foundation -� Property Line i "I E t ... _ LEACHING LINE .� , „Q; J . No. & Length of lines - Total length/size' } a „{ r y r FILTER BED' i ❑j �Oistancl to nearest: Well Foundation Property Line } SEEPAGE PITS ElSize I Number i SUMPS , El Distance to nearest: Well Foundatioq Property Line DISPOSAL PONDS ❑ 1 4 I hereby,certify that I have prepared tkis application and that the work will be done in accordance�nrlth San Joaquin county.ordin`ances, state laws, and rules and regulations of the:San Joaquin Local Health District. # 4 w Home owner or licensed agent's signature certifies the following: "I certify that in the performance of th ,, ork for"11h this permit is issued, 1.shall not employ any person in such manner as to become subject to workman's compensation laws of Calsub -contracting Contractor's hiring or su -contracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall,employ person's subiect to workman's compensa- tion laws of California." The applicant call for all req d tions Complete drawing on reverse si . I f e �- l q �+�} Signed X ' - I - Title: �`1. iDate: [[ !/ !// ( - r s _ qi ,. I j r `yy FOR DEPARTMENT USE ONLY,, Application Accepted by I•1 r - _ Dat - /Vl Area 1' Pit or Grout Inspection by '' Date Final Inspection by Date Additional Comments: -W-,F- ❑ Stk 466-6781 El Lodi 369-3621 ❑ 11 5hteca--1823-71.04.x• yracV 835-6385 No Applicant-Return all copies_to: Environmental Health Permit/Services,1601 E:Hazelton.Ave.,.P.O. Box 2009, Stk.,.CA 95201 all r FEE AMOUNT DUE, AMOUNT REMITTED 'CAS INFO W RECEIVED BY DATE PERMIT'NO. {y C r �7 '* EH 13-24(REV.,/H 5) V S f sir. •��/t X"7��7 EH 14-28 03