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ip� APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 2 � 1601 E. HAZE T ON AVE., STOCKTON, CA f ✓f Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED �a (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 VAN 01 City Sl. Lot Size -4 ORES PM (f, Owner's Name A r 77,E, Address ` Phone l Contractor ® Address ' W"License No. [�' Phone TYPE OF WELL/PUMP: NEW WELL WELL RPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR Q OTHER ❑ 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 I ❑ Industrial ❑ Open Bottom ❑ Manteca Dia- of Well Excavation Dia. of Well Casing - K7 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications 1-1 Public ❑ Other n Delta Depth of Grout Seal Type of Grout _ I I Irrigation __-Approx. Depth l I Eastern Surface Seal Installed by f � - Repair Work Done 0 Type of Pump H:P. State Work DoneWell Destruction ❑ Well Diameter Sealing Material (top 50') ` Depth Filler Material (Below 50') a TYPE OF SEPTIC WORK: NEW INSTALLATION)( REPAIR/ADDITION I I DESTRUCTION i I (No septic system permitted it public sewer is available within 200 feet.) } Installation will serve: Residence t, Commercial— Other { Number of living units: L Number of bedrooms i Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK IN Type/Mfg Capacity 26 a No. Compartments PKG TREATMENT PLT. ❑ Method of Disposal �\ Distance to nearest: Well /2 a/ Foundation Property Line j x LEACHING LINE No. & Length of linesIRSr Total length/size FILTER BED L) "Distance so nearest: Weil F.undabon CL Property Line SEEPAGE PITS I I Depth A Size Number i F SUMPS - �, Distance to nearest: Well Foundation Property[ 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 District. r 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 performance of the work for which this permit is issued, I shall employ persons subject to workmar's co~n`e_1.Ea— ' tion laws of California." ; The applicant must call all required inspections. Complete drawing on reverse side. - Signed 9 Title: Date: FOR DEPARTMENT USE ONLY Ap Ii ti Accepted by Date Area Grout Inspection by �+ Date 7-1 _ Final Inspection by � Date Additional Cdrlrz,ents: ❑ Stk 466-8781' ❑ Lodi 369-3621. .❑ Manteca 623-7104 El Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 85201 FEEINFO AMOUNT DUE AMOUNT REMITTED CASH R 41 ECEIVED BY DATE PERMIT'NO. +.EH13-21(REV.i/FS 5) EH 1I-211 C