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r i fa _ _ APPLICATION'FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA `] 1 Telephone (209) 466-6781 f (/ PERMIT. EXPIRES 1 YEAR FROM DATE ISSUED f - ` (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 welUpump and the Rules and Regulations of the San Joaquin Local Health District. Job Address -qY ` 35 3cp lv 4p b, _ City ' Lot Size �3 PM Owner's Name- �o!!16� Address _ A- f •A/A1-41VC- lPhone Contractor &Z Q zZP-- Address A± - License No. P 5a- Phone TYPE OF WELL/PUMP: NEW WELL ❑ 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 n INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial . ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing . ❑ Domestic/Private "0 Gravel Pack ❑ Tracy Type of Casing Specifications (`l Public �y .J�f --Other - n,� Ci Delta Depth of Grout Seal Type of Grout _ -` t 1 i 1 e, III i I Irrigatioi1 `.App Depth l I Eastern Surface Seal installed by , Repair .. 7DOne ❑ Type of PuiK H.P. Estate Work-Done- Well Destruction of-I Well Diameter Sealing Material (top 501 T ,Depth r Filler Material (Below 50'1 TYPE OF SEPTIC WOO NEW INSALLATION14 REPAIR/ADDITION I I DESTRUCTION I 1 (No septic system permitted ifpublicsewer is available within 200 feet.) Installatir ri iA serve: Residence Commercial_ Other Number wing unit§; !� _ Number of bedrooms_ •Character-pf soil-to' a depth'of 3 felt: i _Water table depth SEPTIC TANi 'p Type/hk Capacity No. Compartments i PKG.,TF EA ��TENT PLT.•Q Method of Disposal Distan t#o nearest:_ WII -Fg4Nation Property Line , LEACHING LINE (f�No:_;&_Length of Iines' s � r s s { Total length/size FILTER BED -�Distance,to=nearest. �--.*Well Foundation iR Property Line f SEEPAGE PITS: I'I, 'DetIn /% r Size d~ p �e Number SUMPS Distance to neaest: Well Foundation Gah F Property Line J - 4 rg �- - DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work will be ii_ohe 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 thaI.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." t The applicant-must-cal far all r quired inspections. Complete drawing on reverse side. . Signed X r Title: ' - Date: OR ART MENT USE ONLY ��4F7 Application Accepted by 7 '" I Date r Area 13 t Pit or Grout:Inspection by bate Final Inspection by Data Additional Comments: -- _ r ❑ Stk 466-6781 ❑ Lodi 369-3621 Manteca 823-7104 ❑ Tracy 535-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE)NFO AMOUNT DUE ~AMOUNT REMIT I ED CASH RECEIVED BY DATE PERMIT'NO. T " + EH 1324