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^v: k APPLICATION FOR PERMIT "4 " SAN JOAQUIN LOCAL HEALTH DISTRICT . 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone 12091 466-6781 b Lk- PERMIT`EXPIRES 1YEAR FROM DATE ISSUED (Complete in Triplicate) .. Health District for permit to construct and/or install the herein described. This application is Application is hereby made to the San Joaquin Local P k made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for welllpump the Rules a Regulations of tlSancJoaquin Local Health District. Job Address City� -- Lot Size PM Fc. = S,4xlE Phone .. ,...� Owner's Name G .n9 ,4 d T' Address ' License No. Hyl Y7 Phone Contractor '` r Af ddress a TYPE OF WELL/PUMP: NEW WELL ❑ +,,ter ; WELL_REPLACEMENT F1 DESTRUCTION ❑ PUMP INSTALLATION t SYSTEM-REPAIR ❑ OTHER ❑1 E rr DISTANCE TO NEAREST:, SEPTI'G,TANK °„ SEWER LINES "DISPOSAL FLi7. PROP. LINE FOUNDATION AGRICULTUW.ELL OTHER WELL PITS/SUMPS INTENDED USE .� TYPEOFWELL PROBLEM A .CONSTRUCTION SPECIFICATIONS ❑ Industrial [J-:Open Bottom ❑ M eca � Dia. of Well Excavation Dia- of Well Casing I ' Specifications k j ❑ Domestic/Private ':❑-Gravel Pack �� aTacy Type of Casing P ❑ Delta DEj th-ol Grout Seal Type'of^'Grout f'1 Public fl Other 5 i I I Irrigation = -ApProx. epth l 1 Eastern Surface'Seal Installed by _ Repair Work Done 11 Type of'Pump H.P. State Work,Done Well Destruction ❑ `Well Diamei-r Sealing Material Itop 501. Depth -Filler Material (Below 50'111, TYPE OF SEPTIC WORK: NEW INSTALLATION X REPAkRlADl)1TION l 1 DESTRUCTION I 1 (No septic-system permitted if public sewer.is ''available within 200 feet.) Installation will salve: Residence Commercial Other . t . 5 Number of living units: Number of bedrooms ,- Character of soil to a depth of 3 feet: -Water table depth SEPTIC TANK Type/Mfg Capacity No. Compartments y Method of Disposal PKG. TREATMENT PLT. ❑ Distance to neares% well /SD Foundation /r? f Property Line' LEACHING LINE No. & Length of lines '100 Total length/size O �A. 2 2 FILTER BED ED Distance to nearest: Well flo/J` Foundation—:5 V Property Line ` J' ' Number -3 1 'SEEPAGE PITS'-- [��I Depth = � Size —'� SUMPS Ll Distance to nearest: Well Foundation 4,340' Property Line -: 7er7 Z. r '. DISPOSAL7PONDS ❑ . I hereby certify that I have prepared this application and that!he,-work-will-be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. * '41,_'`$ ,. r Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work fog 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.”Contractot's hiring or sub-contracting signature certifies the following; "I certify that in the performance of the work for whicii;this.pe'rmit is issued, I shall employ persons subject to workman's compensa- tion laws of California." The applicant must call for all required inspections. Complete drawing on reverse side. f - w Signed XTitle: i Date: EPARTMENT USE ONLY. 4, . o lcatin Accepted by --�YDate, �3 Area /adpa,"tion,l orGroutInspection by Date Final Inspection bComments: ❑ Silk 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, Stk., CA 95201 NT DUE AMOUNT-REMITTED ' 0 CK ;RECEIVED BY DATE PERMIT'NO. FEE 'mow_ � - --- . I �_INFOY -- - - � �]- -,59 /^ ♦ EH 13-24 SrtEV.t/n sl rf'!c;"') �. 3�L�'3 �/U CIO �p` EH 1428