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i APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEILTON AVE., STOCKTON, CA Telephone 12091 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. 1562 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. ` Job Address �9 �7 OfA te_�_e �`,�L V4F City -SQ'L04 Lot Size�� PM Owner's Name - `pm0 Addressy �- - - - `�G- f`-� ��,�y4 C+ Phone � x _() A Contractor's Nams 0�SQ h.� ftf CSC 1ty'L License No. Lr38 46-70Phone<7 `�� TYPE OF WELL/PUMP: NEW WELL 171' WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST:.SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE STYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 0 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing' ❑-Domestic/Private - ❑ Gravel Pack ""` 0-Tracy-- Type of Casing Specifications ❑ Public - , ❑ Other ❑ Delta Depth of Grout Seal Type of.Grout ❑,Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by -Repair Work Done": ❑ «Type of Pump H.P. State Work Done r ) Well Destruction Cl Well Diameter Sealing Material [top 501 _ �I Depth Filler Material {Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION-El 'DESTRUCTION El (No septic system-permitted if public sewer is J F. available within 200 feet.) 0 lnstallatiori will serve:,,Residence I-- Commercial— Other _ 4 4 ~~ 0- Number Number of living units:il — Number of be rooms �~ Character of soil to a depth of 3 feet: IAIIII 044 Water table depth SEPTIC TANK h Type/Mfg of'e-C 1h Capacity Q 1-No. Compartments PKG. TREATMENT PLT. ❑ Method of'Disposal ',7 Distance to nearest: -Well Foundation Property Line _ - r LEACHING LINE � No. & Length of lines 116 f mr-S To�tal..length/size �^ FILTER BED El Distance to nearest: Well ® Foundation--20 I*- Property Line k SEEPAGE PITS ❑ Depth II 2 Size �� 2 Number SUMPS Distance to nearest: Well f Foundation Property Line r� DISPOSAL PONDS EI 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 in such manner as to become subject to workman's compensation laws of California."Contractors 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 Califo ia." The applicant m II for all r quired inspections. Complete drawing on reverse sib Signed Title: Date: FOR DEPARTM T USE ONLY 3- - � ! Application Accepted by Date Area Pit or Grout Inspection by Date Final inspection by 0 Date ' lJ�rv-�{✓'1 Additional Comments; f - ' Or �� 0 1/G7^ O �'P.✓ El 466-6751 ❑ Lodi 369-3621 Manteca 523-7104 ❑ Tracy 835-6355 Applicant- Return all copies to: Environmental ealt Permit/Services 1601 E. Hazelton Ave., P.O. Box 2W9, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIV NO. ©U + EH 1324(REV.101831 _79 'EH 14-26 �.