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APPLICATION FOR PERMIT . SAN JOAQUIN LOCAL HEALTH DISTRICT �y 1601 E. HAZEL T ON AVE., STOCKTON, CA 1 Telephone (209) 466-6781, !�[ 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 welUpump and the Rules and Regulations of the San Joaquin Local Health District. ` Job Address X 7510V' ISLY d ��' City rYA-10-Y Lot Size /it PM 'Owner's Name F�'� - Woo 'IV �`Address� .... - - s _ _-. � Phone' Contractor 0,44,r -SAH' Address 44 /gLV� v License No. yy�'�`�� Phone_��• ��TYPE OF OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT C] DESTRUCTION © ' PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ _ „ a DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE + FOUNDATION AGRICULTURE WELL OTHER WELL _ PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS a f 11 Industrial L) Open Bottom © Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack P Tracy- Type-of Casing= I Specifications l Public ❑ Other ' ❑ Delta Depth of Grout Seal Type of Grout I 1 Irrigation _Approx. Depth } i I Eastern .�F_Surfaca Seal Installed,by - Repair Work Done ❑ Type of Pump H.P. State Work Done c Well Destruction ❑ Well Diameter f Sealing Material (top 50'1 { Depth t Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION IR 'REPAIR/ADDITION l ) DESTRUCTION l 1. (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence 1 Commercial_ Other t r' Number;of living units: _.-� Number of bedrooms _.__-._- t Character of soil to a depth of 3 feet: f 4 "09,0 � i Water table depth SEPTIC TANK ® Type/Mfg p�'t c.4,r Capacity X604 No. Compartments PKG. TREATMENT PLT. Cl ` k Method of Disposal r, { Distance to nearest: Well ado Foundation.. ......`,Pco6i rty.Line- J. LEACHING LINE .el No. & Length of lines Total length/size rte' '• FILTER BED_ ❑ Distance to nearest: Well Foundation gr`. Property Line ?O r SEEPAGE PITS r I Depth Size Number I SUMPS �'� ❑ Distance to nearest: Well Foundation Property Line DISPOSAL-PONDS ❑ I hereby cerfify that i have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and f rules and regulations of the San Joaquin Local Health District. I i 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 for all required inspections. Complete drawing on reverse side. Y Signed X Title: Date: _A l ` FO EP ENT.USE ONLY ' r4Application Accepted by Date ;2i- 7 '�j Area t Pit or Grout Inspection by Date Final I pe ti n b ate Additional rComments: ` ❑ Stk 466-6781 171 Lodi 369-3621 EI Manteca 823-7104 ❑ Tracy 835-6385 [ Applicant - Return telco i o: Environme tal Health Permit/ Lceac3 Vol 111E. Haze in Avp., P.O. Box 009, Sttlk�,,CA 95201 IFEE NFO AMOUNT DUE AMOUNT REMITTED CASH _ RECEIVED BY DATE PERMIT-NO. + EH 13-24 VIEV.i/ry - EH 14-26 r