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s APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is Ijel'eby made to the San Joaquin Local Health District for a permit to construct and4af,install the work herein described. This application is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for worpump and the Rules and Regulations of the San Joaquin Local Health District. Job Address' - _ City.� Lot Size �'� � PM / ,. Owner's Na' Address Address �7 OC/� 4Vr �� i' 6r Phone Contract L_�, tCG�C ifLt`Y� Address PIP 70 6 License No �b'�z� Phones (,tE TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST:.�EPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOl•FNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS ahs INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom CI Manteca Dia. of Well Excavation Dia. of Well Casing s1; CF-19 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications 1 . f l Public J. ❑ Other ❑ Delta Depth of Grout Seal Type of Grout I,I}Irrigation -! r- ._-`_Approx. Depth I 1 Eastern Surface Sea! Installed by _ C__Repair W�k Done , 12—Type-of Pump -H.P.- — — State Work Done Well Destruction , ❑ Well Diameter # Sealing Material {top 501 CA Depth ,;Filler Material (Below 501 Q AoTYPE Of_SEPTIC WORK: NEW INSTALLATION REPAIRIADDITION t i' DESTRUCTION I 1 (No septic system permitted if public sewer is available within 200 feet.) Installation will serve " Residence_ Commercial Other Number of living unitsF- Number of i room Character of soil to a-depth of 3 feet: fir•! - Watei table depth SEPTIC TANK I )< Type/Mfg Capaeity,ZL)o � No. Compartments PKG. TREATMENT;PLT. ❑. f T _ Method of Disposal-- 7 Distance to nearest: Well� = Foundation /. ---- Property Line 5- LEACHING LINE No. & Length of lines Total length/size A20 K Z-. FILTER BED 0.. Distance to nearest: Well Foundation //�_ Property Line SEEPAGE PITS 1Q Depth Size Number SUMPS 0 Distance to nearest: Well/06 Foundation1! _ Property Line DISPOSAL PONDS ❑ `" I 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 forwhich..this permit is issued, I shall not s 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, l shall employ persons subject to workman's compensa- tion laws of California." s The applicant mus It for all ire inspections: Complete drawing.on.tever5e std Signed X 7"� r� Title: P , ^ Date: .. FOR PARTMENT USE ONLY Application Accepted by (� Date Area Pit or Grout Inspection by at© final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3651— ❑ 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 FEE INFO AMOUNT DUE AMOUNT REMITTED CK CASH RECEIVED BY DATE PERMIT NO. t.EH 13-24 iREV.1 i 9 51 EH 14-28