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, [[ � APPLICATION FOR PERMIT to SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON 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. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. 00, Job Address 1_00 Z A - &-44PQAd City dLot Size PM Owner's Na CL�.�€STC*tw.RJ� �Iddress �� 954" Phone Contract W Address r License-No Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ w PUMP INSTALLATION ❑ "-fiY TEM-REPAIR-❑"" - =OTNER-`❑'-`- DISTANCE TO NEAREST:'SEPTIC TANK fSEWER`L"1NEk *f ` 0 ISP05AL" FLD. PROP.,LINE + E, - ' FOUNDATION 'AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE . TYPE OF WELL PROBLEM AREA .CONSTRUCTION SPECIFICATIONS 4 ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of, all Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy (Type-of Casing Specifications (`T Public f7 Other Ll Delta _1:Dept`h of Grout Seal Type of Grout I i Irrigation _Approx. Depth I 1 Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump i H.P. State Work Done Well Destruction L Well Diameter. Sealing Material (top 50') \ Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION 1 1 REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is Q -'` r available within 200 feet_) Installation will serve: Residence Commercial--if"'Other 9 , Number of living units: Number o b dms' F '1 +v Character of soil to a depth of 3 feet: 4ro t t• Water table depth SEPTIC TANK *-'Type/Mfg �` Capacity No. Compartments PKG. TREATMENT PLT. ❑ ' ° � t Method of Disposal Distance to nearest: 4 Well ASO Foundation d42140 Property Line 3 LEACHING LINE I"No. & Length of lines r Total length/size FILTER BED ❑ Distance to.nearest: WellFoundation Property Line SEEPAGE PITS fl►r�_Depth -574. —Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONOS ❑ 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 ins ch manner as to become su ct to workman's compensation laws of California."Contractor's hiring or sub-contracting signal re certifies the following• l certify that in the perfor a of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of Calif, a The a pli ant s all for all require ctions. C rowing on raver side. Signe itle: - .. Date: F _ F EPARTI IENT USE ONLY t_ G Application Accepted by Date 1 S f Area •� t ) Pit or Grout Inspection by 4 Date�a Final ltpspection b Dat Additional Comments: ❑ Stk 466-6781 ❑ Lodi• 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6395 Applicant - Return all copies to: Environmental Health Permit/Services 1601`E*Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE i --- 'INFO- -,AMOUNT-DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. a-EH 1 3-244REV.r/H5) /a�� I,1+( �Z�'� EH 14-26 s r C7� p� u i