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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRIC yyyy 1601 E. HAZEL T ON AVE., STOCKTON, CA v Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health Districtfor a permit to construct and/or install ls i } k'66r`tin described. This application is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and the Totes dri��Regi1L11iari of the San Joaquin Local Health District, Job AddressJyj ( 7 City Lot Lot Size PM Owner's Name �a rr y D r,0#04 / - --- Address V Phone ContractorG 1 ddress Z� Wk%Ar4v— License No.7127,& ? TYPE OF WELL/PUMP: NEW WELL)(M ` cELL REPLACEMENT 17 DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ i DISTANCE TO NEAREST: SEPTIC TANK N _2-4!Y*_2-4!Y*A_ SEWER LINES � DISPOSAL FLD. PROP. LINE /h FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Z `� ❑ Industrial ❑ Open Bottom Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/PrivateGravel Pack 12 Tracy Type of CasingGG Specifications _ .�I M Public Ll Other F] Delta Depth of Grout Seal 7 Type of Grout�...L I I Irrigation 41_Approx. Depth I I Eastern Surface Seal Installed by ((( _ Repair Work Done ❑ Type of Pump H,P. State Work Done _ Well Destruction ❑ Well Diameter ZN Sealing Material (top 50') $I". W(u Depth Filler Material (Below 50'1 — TYPE O EPTIC WORK: NEW INSTALLATION l I REPAIR/ADDITION l I DESTRUCTION € I-(No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_ Other lkNumber of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG, TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE Cl No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I 1 Depth Size Number SUMPS Ll Distance to nearest: Well Foundation Property 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 Diltrict. Horne 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 C , ia." The appli t m t call for all re ed inspe 'o omplete drawing on verse s'd //�/� !! Signed X _ Title: !° Date: � FOR DEPARTMENT USE NLY ��fkApplication Accepted by Date ,..I Lan '!S�. Area Pit or Grout Inspection by Date4 Final Inspection by Date_ Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca a23-7104 ❑ Tracy 835.6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Sik., CA 95201 /I FEE AMOUNT DUE AMOUNT REMITTED ASCK# RECEIVED 9Y DATE PERMIT'N0. INFO — +.EH 13.24(REV.t r H 5) �r EH 14-28 �.r