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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES TYEAR FROM DATE ISSUED (Complete in Triplicate) Application is he+eby 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 �`�n -�64 City Lot Size_ _lU PM Owner's Nam r/' '� Ea'' Address Phone # � Contractor � �` Address A10 46 License No, ;�V�Phone � TYPE OF WELL/PUMP: -,--,.-NEW WELL (71WELL REPLACEMENT ❑ DESTRUCTION LJ PUMP INSTALLATIOfV f �`(5TEIIII-ftCP7�lR"C7 p OTHER C] DISTANCE TO NEAREST: SEPTIC TANK SEW�R LINES DISPOSAL FLD. PROP. LINE 1 ND'ATIO6V""'"4--' ILULTURE WELL OTHER WELL PITS/SUMPS I INTENDED USE TYPE OF WELL PROBLEfi AREA CONSTRUCTION SPECIFICATIONS , ❑ Industrial ❑ Open Bottdm ❑Manteca E►iarof-We}I excavation - Dia. of Wel[ Casing ❑ Domestic/Private ❑ Gravel Pack ❑`Tracy Type of --- 1g Specifications 171 Public ❑ Other Cl Delta Depth of Gro t Seal Type of Grout i I,I Irrigation 1 .Approx.;Depth I I Eastern Surface Seal nstalled by Repair Work Done ❑ Type of Pum pi H.P. State Work Done Well Deruction ElWeIl iamete � Sealing Material Itop SO) I Depth Filler Material {Below 501 TYPE OF SEPTIC WORK: NEW INSTNLLATION [ EPAIR/ADDITION 1 1 DESTRUCTION f I (No septic system permitted if public sewer is J i II available Within 200 feet.) Installation'lwill serve: Residence •—y Commercial_ Other ,a 'f r Number of living units: Number of bedrooms ___._ 1 ! f Character of soil to a depth,03 feet:+ r Water table depth j SEPTIC T, �a AT Type/M.� ; Capacity CDU -- No. Compartments 2, t t QKG.�TREATMENT PLT.,❑ "3 Method of Disp�sal ' f4. r F fir/ pistancq to nearest: Well,/6Foundation I� roperty Line LEACHING LINE E N & Length of lines �; "-� Total length/size i •� f' FILTER BED r D D tance to nearest: Well Foundations ,i* � Prop s y Line11 SEEPAGE PITS Depth �� Size Y ! b Ne Number"" t SUMPS ' Distance to nearest: Well, /5' foundation /-/0 Property Line ld DISPOSAL BONDS ❑ s 4 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 Joaquinhocal Health District. j 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 anyiperson 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 compnsa- tion laws of California." h, can The app Thli {{t m all for t,raquire nspections. Complete drawing on reverse side. _ f ;r r Signed Title: Date: 1-h F. �PA�ENT USE ONLY k Application Accepted by —< Date r � Area / r !! , _ ' ! Pit or GroutAlnspection by Data �_1- Final`itisFction by Date/ f " _.- � Additional Comments: �� ..._ ❑ Stk.-466-6781.—�--❑.,Lodi...-369-3621 .Q-Manteca-823-7104 L�racy--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 CASH RECEIVED BY DATE PERMIT'NO. INFO At +AH13-24iREV,I/A5) 7,0 tar EH 14-26 !