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APPLICATION FOR PERMIT a 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 hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. This application is I 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 251 City Lot Size PM € Owner's Name e Address �S c Vt1�(j/t� _ I9R'7 ContractoP�+�1 � " a.iL�W Address�:)" 1`7(9'?( V7 AJ`i- _License 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 OTHER WELL PITS/SUMPS; lPil INTENDED USE _ TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial LJ Open Bottom ❑ Manteca Ria. of Well Excavation Dia. of Well Casing ❑ Domestic/Private CJ Gravel Pack ❑ Tracy Type of Casing Specifications M Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout I 1 Irrigation _-,Approx. Depth I 1 Eastern Surlace Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work pone_ Well Destruction ❑ Well Diameter Sealing Material {top 50'I Depth Filler Material (Below 501) TYPE OF SEPTIC'WORK:,vNEW INSTALLATION IAr REPAIR/ADDITION I I DESTRUCTION l I (No septic system permitted if public sewer is y� '� available within 200 feet.) Installation will serve:' Residence Commercial Other Number of living units: Number f1bedroo s t Character of soil to a depth of 13 feet; SEPTIC TANK L�' Type/Mfg(' ' -- Water table dep No. th Capacity NoCrtments PKG. TREATMENT PLT. ❑ t f� ?� �;R � � �� ` ! � ,Method of Disppsal 4 Distance to'neareM- Well–1�� — Foundation – Pr=operty Line -! LEACHING LINE L"Nq�i Length/`of links Total length/size 10 A, �^ FILTER BED ❑ stance to nearest: Well - . _ Di � Foundation 10 Property Line k __ SEEPAGE PITS 16- Depth '' _ Size_�� * Number DISPOSAL PONDS SUMPS CI Distancia nearest: Well._) L71�_'Foundation �( _:_ Property Line I ❑ 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: "f certify that in tie�rformance of the work for which this-permit is issued, f shall not employ y person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature certifies laws ofthe f Claliforna,.4 certifythat in the performance of the work for w¢ch'fhis permit is issued, I shall employ parsons subject to workman's compensa The applicant m call for all ire inspections. Complete drawing on reverse sid ° Signed Title: r Date: CQV t FOR DEPARTMENT USE ONLY Application Accepted b Date Af e 4 J r i1 r Grout inspection by Date / Final Inspection byJ Date Additional Comments: ❑ Stk 466-6781 ❑ 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, Silk., CA 95201 FEE AMOUNT DUE AMOUN REMITTED CK I INFO CASH RECEIVED BY DATE EP�RMITO. EH 13-24IREV,r/asl 'EH 14-28 ! - ,.