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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone 1209) 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.2000f), r�� ,�n� /y� Job Address V�0OJEA &_ City i"�� Lot Size SO )( PM Owner's Name Ft`AM('"I S Address J Pexe- Phone Contractor If I�1 '�-eAddress S $� �'� fie. License No. 29'39101 Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTdL'G�Tft D " ` YSI`ENI i Af ----OT-HER--[9 •^•- 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 ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications f"1 Public 1711 Other Ll Delta Depth of Grout Seal Type of Grout } I I Irrigation —_Approx. Depth I 1 Eastern Surface Seal Installed by _ G Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material ltop 50'i Depth Filler Material (Below ') !� TYPE OF SEPTIC WORK: NEW INSTALLATION l 1 REPAIR/ADDITION 10--DESTRUCTION l I INo septic system permitted if public sewer is " available within 200 feet.) Installation will serve: Residence Z Commercial____ Other 7 Number of living units: Number of be ooms 2- Character Character of soil to a depth of 3 feet: AkNiA)e Water table depth O SEPTIC TANK ❑ Type/Mfg ' Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal I Distance to nearest: Well Foundation Property Line r LEACHING LINE Cl No. & Length of lines _ '. _. Total length/size FILTER BED Wr Distance to nearest: Well �3 Foundation ��; Property Line 20 --- - /1U5CA i I 10 X .— F.Lr*,� � To ar)asr� c 5y SEEPAGE PITS I I Depth Size _ Number SUMPS 0 Distance to nearest: Well Foun atiori' ""� "property Line DISPOSAL PONDS ❑ 1 hereby certify that I have prepared this application and that the work will be done in accordance with Sart 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 per( mance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." The applicant m 11 for all re uired inspe ons. Complete drawing on reverse side. ! Signed e)lr Title: ^ Date: f ��'g� ~ r! FOR DEPARTMENT USE ONLY Application Accepted by Date Pit or Grout inspection y - Date - Final.Inspection by- - Dat�p Additional Comments: _-0 Stk 466-6781 - 0.Lodi -369-3621 ❑ Manteca .823-7104 - - p Tracy 835-6385-- - - -- -- - Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT'NO. INFO CA + EH13-241REV,Fi 4sl p �� 10'S- 81-a�btu EH 14-26