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r rr APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES TYEAR 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. tt Job Address 2 A 86.5' '5q' G Cf X4 13 , City 7_?'11C Lot Size �•'itwc-h 0,41c I Owner's Name GYerA Address 1�t86s' -57 131 rot ' Phone i Contfactor /Yr QI1/ SO/V Address OWR QGv� tet"1 License No.`fYy-�4� Phone�'��'�� t TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DMTANCE``f0 NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS I INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS b Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Ell Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications f'1 Public 17 Other Ci Delta Depth of Grout Seal Type of Grout __ ISE irrigation —..Approx. Depth l l Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done r Well DesinLion ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 50') — 1 TYPE OF SEPTIC WORK: NEW INSTALLATION I1 REPAIR/ADDITION DESTRUCTION l I+INo septic system permitted if public sewer is n available within 200 feet.] Installation will serve: Residence J_ Commercial— Other' Number of living units: I Number of bedrooms -1- d Character of soil to a depth of 3 feet: i y 4r4ly r Water table depth l f\ SEPTIC TANK Or- Type/Mfg 9W 1 7: 'Capacity 1 A&0` No. Compartments r PKG. TREATMENT PLT. ❑ Casty Method of Disposal Distance to nearest: Weir JAQQ,� Foundation~, 1 Property Line 100 LEACHING LINE Vf No. & Length of lines lflfl Total lengthlsize iZ00 FILTER BED ❑ Distance to nearest: Well �Bp Foundation 'TSS Property Line ' SEEPAGE PITS I'I Depth Size Number �.4 SUMPS 0 Distance to nearest: # - Well Foundation Property Line I DISPOSAL PONDS ❑ v- IFhereby.certify that I have prepared this application and that the work will be done in accordance.with San Joaquin county ordinances, state laws, and t 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.":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 fo workman's compensa- tion laws of California." ' The applicant must call for all required inspections. Complete drawing on reverse side. t Signed X � ,c Title: Date: y V-71 F i FOR DEPARTMENT USE ONLY rte, Application Accepted by "�; Date �Area f `v Pit or Grout Inspection by Date Final Inspection by Date s 3 I Additional Comments: d ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ M teca 823-7104 ❑ Tracy 5-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. INFO �jCASH �y �.EH 13-24 IREV.I R5) 11 �� 1 f� jz,l UJ y {,�•1�� EH 14-26