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e. 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 A (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 Ordi ante�N/o.549 for sewage or a. 862 for w Ilpu end the Rules and/Regula�ans�o�f the V)CV,Joaquin Local Health District. // O f y C�L ` 4 � a `� �f �" 1r-1 ""�+ 4 Job Address I W rr I City Lot Size e� __ __R_ESPM Owner's Name 54v' — Address /� _ ) Phon15 e ,tet � ry Contractor 4L Y _ Addressf, '� J �0 � License Ne��q�Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ ,,,_;;- PUMP,INSTALLATION,0— _ 4 SYSTEM .REPAIR ❑, _ � k OTHER-❑-- 1 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. 'sPROP'.LINE FOUNDATION AGRICULTURE WELL OTHER:WELL PITS/SUMPS INTENDED USE TYPE OF WELL-N - PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private �_❑-Gravel Pack . ❑,Tracy•,,,,,, . Type-of-Casing ----- Specifications I.1 Public ❑ Other n, Delta Depth of Grout Seal Type of Grout I I Irrigation _.-Approx. Depth— :I.Eastern Surface Seal Installed by - Repair Work Dane ❑ , Type of Pump - H.Pf -" State Work Done Well Destruction 1711Well Diameter Sealing Material (top 50') y - Depth - Filler Material (Below`50')' r - TYPE OF SEPTIC WORK: .-NEW INSTALLATION - REPAIR/ DDITION I I• DESTRUCTION I ) INo septic system permitted if public sewer is .ti. , ' " � .1 - available within 200 feed Installation will server Residence_ Commercial_ Other ;iGy w Number of living units: Number of.bedroof4s= j A +1 ,r W Character of soil to a depth of 3 feet: ' Water table depth SEPTIC TANk" Type/Mfg Capacity r'-_1#100 No. Compartments PKG.,TREATMENT-PLT. ❑ �" _ j Method of Disosal F� Distance to nearest:• r 1Well Foundation ! Property Line LEACHING'I.INE4'-V- Cl No.&Length of line's 7 9"X a 9 Total length/size f FILTER BED f.1 . Distance to nearest:' ' Well_O !_ Foundation Q1_._-_..... Property;Line;S SEEPAGE PITS I I Depth Size Number SUMPS _y ,❑.—Distance.to nearest::. Well Foundation Property Line + DISPOSAL PONDS ❑ ire 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'Sari 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 must call f all re d inspections. Complete drawing o=de. rde. Signed X Title: �/-(/r -/ Date: a� FOR DEPARTMENT USE ONLY Application Accepted by Date V Area �p Pit or Grout Inspectio Date Final Inspection by Dater O t7 Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 623-7104 - ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK 4t INFO CASH RECEIVED BY DATE PERMIT NO. +.EH 13-24 IRM t/N5S 76 .4 - �fY EH 14-26