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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZETON 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. Q r y Job Address _13J� 5 ahwau CDM _ City LZ6%�"O�'SL Lot Size 1�•x ILS+ PM Owner's Name R0 ��1t��i45 /5 ZIrbC tit1C, Address 114° in L B IZ. Phone 77r;J1ee ,JAA-WM W%.*P.AT%aN , Pt-ITSg0IiG,cA C-g'} LdC.--*4 C$OZ [ArlsV errtFactor l'%RAC= Ci15 Address 437-55 Wk SSSibn BXIIa----License No.C66 17-fa+ Phone ts'fasl-19 TYPE OF WELL/PUMP: NEW WELLb< 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 , INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 1 ❑ Industrial El Open Bottom El Manteca Dia. of Well Excavation 9" Dia. of Well Casing 211 ❑ Domestic/Private %4 Gravel Pack ❑ Tracy Type of Casing SCh 40 PyC Specifications i`l Public ❑ Other ❑ Delta Depth of Grout Seal , 4 S' Type of Grout t14L* 1t" %,AUWe,h,3 ^ 5C1.Approx. Depth l 1 Eastern Surface Seal Installed by ftU%-,�2A*A5 w ben-}on-tilt- _ Repair Work Done ❑ Type of Pump NA H.P. State Work Done Well Destruction ❑ Well Diameter , Sealing Material Itop ! '1 B i- %. Depth " S4 + Filler Material IBelow VI) TYPE OF SEPTIC WORK: NEW INSTALLATION [I REPAIR/ADDITION i I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.► Installation will serve: Residence_ Commercial— Other�✓ Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Cap -No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: ell Foundation Property Line LEACHING LINE ❑ No. & Length of lin Total length/size FILTER BED ❑ Distance to rest: Well Foundation arty Line SEEPAGE PITS I ] epth Size - -Number SUMPS C Distance to nearest: Well Foundation 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 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 m s a I r ins ions. Complete drawing on reverse side. �7 Signed X Title: _ r Date: sits(8r R TMENT USE ONLY Application Accept Date Area ] Pit or I& s tion by Date « T Final Inspection by 1 1 1- Additional Comments: ❑ Stk 466-6781 ❑ Lodi 621 ❑ Ma eco 104 ❑ Tracy 835-6MS ®/ Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 r INFO FEE AMOUNT DUES AMOUNT REMITTED CASH RECEIVED BY DATE PERMII''NO. 10- . EH 13-24(REV.i/m 51 EH 14-26 tjf/1 5< ,��^ < ,`}�