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APPLICATION FOR PERMIT L4'L�o SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 i 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. Job Address _J �jC�- !Yi�ts-(' a City Lot Size PM Owner's Name Address s2_75-1 v Phone Contrac Addresszg�Zlo phone License No. TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT Q DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS t INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial I 'T — O,Open Bottom © Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications 1-1 Public f_i Other } I f 1 Delta Depth of Grout Sea! Type of Grout _ I I Irrigation w ` ..Apprii>t. Depth I 1 Eastern Surface Seal Installed by Repair Work Done F❑�F 7 pw of.Pump H.P. State Work Done_ `+ Well Destruction . ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 50') �1 TYPE OF SEPTIC WORK: NEW INST�TION IJ REPAIR ADDITION DESTRUCTION I I (No septic system permitted if public sewer is �f available within 200 feet.) 1 Installation will serve: Res ence , :Commercial ther / Number of living units: Number of hedr ms Character of soil to a depth of 3 feet: Water table depth -� SEPTIC TANK ❑ IType7Mf _. Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance.to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines - Total length/size, }- FILTER BED ❑ Distance to nearest: Well 4 ,-'r�`Foundation ' y Li -t _ Property line SEEPAGE PITS i I Depth Size !!J < Number SUMPS Distance to nearest: DISPOSAL PONDS L�1 Well 19 Foundation��a _ Property Line-- � 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." Contractors hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued,1 shall employ persons subject to workman's compensa- tion laws of Calif rnia." The applicant mu call for alreq ire inspections. Complete drawing on reverse si e. Signed X Q Title: Date:/Arwt /� ^ FOR DEPARTMENT USE ONLY C� / Application Accepted by��'-PJ/ `�/�9 Gem Date L7° /�� "`�-- �- - f�— Area Pit or Grout Inspection by Date Final Inspection by T_ej /")Date Additional Comments: + ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 0 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 i INFO 11 CASH RECEIVED BY DATE PERMIT NO. +.EH H 13-24(REV,tin5) t \ EH 14-2e J f S