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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 (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 11J7ILn U K) 1--f L}CA 'En Pd City c�>c ,S tct 3. Lot Size - t PMS Owner's Name no5 Y t I-I (-)0)l�J Jl�� Address c21 S)q7 C LSSUS 1 �C/Phone -«tCLY�t ContractoorrTf� rf �'a�' 1 Address_ �l�t� R License No. 7 U0- )? Phone TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION�SPC SYSTEM�REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST; SEPTIC TANK r��d�JL``',�_-.�_- SEWER LINES JU1L DISPOSAL FL PROP. LlNE4. 5 1 FOUNDATION AGRICULTURE WELL Ah2�kOTHER WELL_ PITS/SUMPS ajAt INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS L J ❑ Industrial ❑ Open Bottom ❑ Manteca Dia, of Well Excavation Dia. of Well Casing 1 [.Domestic/Private Gravel Pack ❑ Tracy Type of CasingSpecifications �r,. I I Public Cl Other ❑ Delta Depth of Grout Seal s�� Type of Grout&_1 J T_. I I Irrigation _Approx. Depth I I Eastern Surfce Seal Installed by J Repair Work Done Type of Pump S H.P. State Work Done _ \j Well Destruction ❑ Well Diameter ! Sealing Material (top 50') Depth Filler Material (Below 501 TYPE OF SEPTIC WORK:. NEW INSTALLATION 1.1 REPAIR/ADDITION I. I DESTRUCTION l I (No septic system permitted if public sewer i�, y available within 200 feet.) 4 Installation will serve: Residence_ Commercial Other Number of living units: Number of bedrooms Character of sol'to a depth of 3 feet: _ Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG, TREATMENT PLT. ❑ Method of Disposal_ Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line i SEEPAGE PITS I 1 Depth Size T Number SUMPS L� Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I 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`,Joaquiri Local Health 1311trict,— 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 workman's compensa- tion laws of California." The applicanrrryst call for all required i FIFFctions. Comp to drawing on reverse side. i Signed Title: 1Q� �� Date: OF `-F DEPARTMENT USE ONLY Application Accepted by A10C.—I IL 4Ai.wnAM/�_ Date 5 Area d Pit or Grout Inspection by _Z Date Final Inspection by Dater Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601. E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED 11 SH RECEIVED BY DATE PERMIT'NO. +.EH3-24tREY E 14-28 .riKs1 D�,oa H f