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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZETON AVE., STOCKTON, CA 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. 1662 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. r r �f 2 Job Address 3-7 ` fir cy City ` 00?1 Lot Size � [ ✓ 7 fZPM Owner's Name 06 r, CO-ry tS Address r+'[i hone Contractor �_..__!� t,E�� Address G License No �.� Phone r3 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR D OTHER ❑ 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 'Y D Industrial ❑ Open Bottom D Manteca Dia. of Well Excavation Dia. of Well Casing w 0 Domestic/Private ❑ Gravel Pack D Tracy Type of Casing Specifications I"1 Public ❑ Other FI Delta Depth of Grout Seal Type of Grout _. n I I Irrigation --Approx. Depth I I Eastern Surface Seal Installed by _ _,1 �[ Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material itop 501 1 Depth Filter Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION l I DESTRUCTION l I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence Commercial_ Other Number of living units: ----1--- Number of be rooms "a + Character of soil to a depth of 3 feet: c0 p C I Water table depth SEPTIC TANK V f Type/Mfg 1�. —� Carlcyr-rA•-e. Capacity 4 No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well lap Foundation le Property t=ine hh LEACHING LINE No. & Length of lines 3 6 Total length/size LV) FILTER BED © Distance to nearest: Well Foundation SL Property Line—1 Iso �J SEEPAGE PITS Depth ( S Size �!r Number J SUMPS Ll Distance to nearest: Welles Foundation 461Property Line DISPOSAL PONDS ❑ 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 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 to workman's compensa- tion laws of California." The applicant must call for all required inspections. Complete drawing on reverse side. Ltd ( Signed Xiii_ �� oY�i4J Title: 54-aft— Date: V FOR DEPARTMENT USE ONLY �-- Application Accepted by - date r Area it r Grout Inspection by Date r inal Inspection by Date ' Additional Comments: -0 Sik 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 1335-(1385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CA H RECEIVED BY DATE PERMIT'NO./{ + EH13-24(REV.I/K5) C �[/Y1 EH 14-26 ,..nry '!T` ! `•�