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} APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 'I'YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to the San Joaquin Local Wealth District for a permit to construct and/or install the work herein described. This application is made in compliance with San Joaquin County Ordinance N 549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. U en Job Address F� City Lot Size . 5�/� PM- Owner's NameAddress �O Phone '- / Contractor (N r '91J5a Address 6 -License lye„?O ��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 INTENDED USE TYPE OF WELL - PROBLEMAREA. CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia” of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout k I I Irrigation _Approx. Depth l I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done �S\ Well Destruction ❑ Well Diameter Sealing Material {top 501 �1 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK. NEW INSTALLATION/N,,REPAIR/ADDITION l 1 DESTRUCTION l I (No septic system permitted if public sewer is C G� available within 200 feet.► Installation will serve: Residence\ Commercial— Other I Number of living units: Number of bedrooms.-_ 3 Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity d0• No. Compartments PKG. TREATMENT PLT. ❑ 1' Method of Disposal � r �C Distance to nearest: Well L� Foundation /6, d - Property Line V -4-- y� f LEACHING LINE if No. & Length of lines � l?_� f! Total igth/size O� �II FILTER BED L] Distance to nearest: Well�4n Foundation j lf0 Property Line j'I Q f r ' SEEPAGE PITS f I Depth 04Size f lumber r � SUMPS Cl Distance to nearest: Well Foundation LkU Property Line_ a _ DISPOSAL PONDS ❑ _,, ' 1 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 workmari's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the performance of the worOfor which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." + 4 : f , The applicant �tf®req�uired �ctions�.-Compldte drawing on reverse side. ti - Signed X Title:' � �. ....-_. Date: /- IZ op FOR DEPARTMENT USE ONLY �Application Accepted by Date + ?� Area ! (PR or Grout Inspectio ate — Final Inspection by / Dat�e"ote (t Gel ,.f '�^ �' rf c,.v �- ' Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-362 ❑ Manteca 823-7104 ❑ Tracy 635-6385 r Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.D. Box 2009, Stk., CA 95201 FEE INFO AMOUNT //°DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT a EH 13-24 IREV,l1/n s7 ti/ �� EH 14-26