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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 'r ? (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 V �` I City % l� Lot Size PM Owner's Name Lac' il-Z/ OLi�_ Address -2-e V 3et / Z Phone Contractor's Name' C D it R - License No. Phone TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ f DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP, LINE FOUNDATION _._._ t�� AGRICULTURE WELL OTHER WELL PITS/SUMPS (kAl) 4j INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS !/ ❑ Industrial ❑ Open Bottom ❑ Manteca..,-• Dia. of Well Excavation—_�� Dia. of Well Casing C, ' j 6/45i�- Specifications ,2FsDomestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing p ❑ Public ❑ Other ❑ Delta Depth of Grout Seal D ype of Grout ❑ Irrigation 1?--�Qpprox.'Depth ❑ Eastern Surface Seal I stalled by Repair Work Done ❑ Type of Pump tl �-aZL H.P. ' State WV Done Well Destruction ❑ WeII Diameter 6 Sealing Material Itop 501 DepthJ.7d!- it 30� _ Filler,Material IBelow 50') * ' TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is ( available within 200 feet.) Installation will serve: Residence_ Commercial___- Other ; Number 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 r PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Leng4h'of lines Total length/size { FILTER BED y❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS �O Depth ' ! Size a Number SUMPS ❑ Distance to nearest: W61 Foundation 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, 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." Contractors hiring or sub-contracting signature certifies the following: "I certFfy 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 mhstFcall'for all required inspections. C"ffriplete drawing on reverse side. �j 1' � � ��/// ,�`l� x.. z} Title: /TK '��- Date: ---, Signed X� — } FOR D ARTMENT USE ONLY g p Application Accepted by Date 2—r O Area Pit or Grout Inspection by Date Final Inspection by Date �� Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3521 0 Manteca 823-7104 ❑ Tracy 835-6385 ! Applicant='Return,all-co les till�E--iron'mental Health Permit/Services 1601 E: Hazelton Ave:, P.O:Box-2009,-Stk., CA 95201 Qror �GJ r_ + Q IFEE 'NFO AMOUNT DUE * `AMOUNT.REMITTED CASH RECEIVED 6Y DATE PERMIY`N0. Of + EH 13.24{REV.10/831 �� "��I Y L/- � EH 14-26 S