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APPLICATION FOR PERMIT - SAN JOAQUIN LOCAL HEALTH DISTRICT 4. u 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209)466-6747_ 4v� S 4;l,0 ¢` PERMIT EXPIRES 4 YEAR FROM DATE ISSUED (Complete in Triplicate) I .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 i iLocal Health District. f Job Address ED �`� �C City Lot Size i4C fE PM Owner's Name \J . J e-T KNEESSeV4- Address _e-2 a(0R la g k7 Phone t?3 I7 / I '°Contractor f �A.n",� f�i'us r_r Address �3 ' G& nse No. Phone. -/ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC.TANK f' -,SEWER LINES- `� sDISPOSAL FLD. &O �ZPROP. LINE FOUNDATION 1 f nfAGRICULTURE WELL OTHER WELL � PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industria! ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ;R Tracy Type of Casing Specifications Ll Public 1-1 Other ❑ Delta Depth of Grout Seal Type of Grout.-- I rout--. _I Irrigation ----Approx. Depth I 1 Eastern Surface Seal Installed by _ t ;Repair Work Done ❑ Type of Pump H.P. State Work Done _ ;Well Destruction 6Y Well Diameter rr Sealing Material (top 50') -p ^J 8� Depth .Z5 Filler Material (Below 50'1 tj — E TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIRIADDITION I I DESTRUCTION I I fNo septic system permitted if public sewer is II available within 200 feet.) Installation will serve: Residence_ Commercial— Other Number of living units: Number of bedrooms 4 Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal ii Distance to nearest: Well Foundation Property Line ij !I LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line I( ,1 SEEPAGE PITS l I Depth Size Number Jj•SUMPS _ _ CI distance to nearest:. Well Foundation. Property Line - . „- -- 1 DISPOSAL PONDS E3. _ _ y 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 II rules and regulations of the San Joaquin Local Health DR;trict. 1j 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 u employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature i 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 for all required inspections. Complete drawing on reverse side. I Af Signed X Title: (.[1r1-� !�` _ Date: /� It ja FOR DEPARTMENT USE ONLY j Q� fl Application Accepted by VAI C^ Date I to q Area et Pit or Grout Inspection by, Date/dcl � Final Inspection bv/"Y1W—M Date S Additional Comments: 1,Q Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 „a}� Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 \f FEE INFO AMOUNT DUE AMOUNT REMITTED CK H RECEIVED BY DATE PERMIT NO. 'EH13.24(REV.I/K5)