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e APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT { 1641 E. HAZLT ON 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. Job Address City, Lot Size 4w- /"PM Owner's NameL� � _._. �� C C� Ems`!/i�► Phone WContractor Address s � •�ense No'. ?one TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ 7 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE ,.y FOUNDATION + "� _° AGR ULTURE WELL OTHER WELL PITS/SUMPS, f INTENDED USE TYPE OF WELL PROBLEM AREA 'CONSTRUCTION SPECIFICATIONS " I I 11 Industrial Ll Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic'/Private ❑ Gravel Pack ❑ Tracy *. Type of•Casing+' Specifications + `� 17P`blit F ElOther El Delta x !Depth of Grout'Seal it' Type of Grout ElWIrrigation"+ --Approx. Depth ❑'Eastern Surface Seal'.Installed by `Repair Work Done ❑i Type of Pump�z I H.P. *4 State,Work_Done Well Destruction ❑� Weil,Diame[er J s" � k.r Sealing Material It6p-50'l- Depth + ' Filler Material {Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ 'REPAIR/ADDITION DESTRUCTION ❑ {Na'septic system permitted if public sewer is C r t available within 200 feet.) t Installation will serve: Residence -Comfllercial.� Othe Number of living units: _ Number of. edroamsili�=." 1 Character~of soil to a depth of 3 feet: 01 Water-table depth i SEPTIC TANK Type/Mfg �/ _! Capacity ew�l._ o. Compartments ✓ PKG. TREATMENT PLT. ❑ +� �:a ''•�s a F t Method ofDi?posai Distance to nearest: Welles' ' / •Foundation }' Property Line �� / t f LEACHING LINE - Noi & Lenith._of_Iihes`�� - R , g I Total.length/size I a{ / 3 FILTER BED ❑' Distant fto.nearesi:. Well Y Foundation �� Property Line ; SEEPAGE PITS ❑ Depth# e4, „_Size Number "*� �"� SUMPS ��(( Distance to nearest: Well Foundation”,* I r t.r J�� Property Line " DISPOSAL PONDS ❑ hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances;staie laws, and + rules and regulations of the San Joaquin Local Health District. 1 i Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit�isrissued, I shall not employ any person in such manner as to become subject to workma'n'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." r j The applican mus II for all required ' ctions.� omplete drawing on reverse side, 1 r Signed • Date: s FOR DEPARTMENT USE ONLY I Application Accepted by date [� /5 Area Pit or Grout Inspection by Date Z A Final Inspection by Date a2 Additional Comments: f ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 93201 FEE AMOUNT DUE AMOUNT REMITTED ,INFO RECEIVED BY t` DATE PERMIT'NO. + EH 1324 IREV.1/e 51 `� 1 Z EH 14-26 /O `c`_ <:', 3193