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t. APPLICATION FOR PERMIT r SAN JOAQUIN LOCAL HEALTH DISTRICT L 1601 E. HAZETON AVE., STOCKTON, CA Re e, �, S il Telephone (209) 466-6781 G�1 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED JUN Z2 ' (Complete in Triplicate) r�F �3�� �VVIR ed. This application is Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the� San Joaquin made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the RuR.1.4me.RVJC Local Health District. Job Address _��®�� R��1in City�A�ls-3-x.r Lot Size PM .Zc796--)9—�12s-1 s u`U�[. �� H11tiE -('� Address Phone Owner's Name � � - Contractor Address License No.-_._z Z 4?'hone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR C] OTHER C�t��►+�"" r"�� L�3C_1_t" k DISTANCE TO NEAREST: SEPTIC TANK :fa SEWER LINES .�2 1_.— DISPOSAL FLD.��_ PROP. LINE FOUNDATION 61D AGRICULTURE WELL OTHER WELL��r PITS/SUMPS A.) y T INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 1-1 Industrial ❑ open Bottom anteca Dia. of Well Excavation Dia. of WeN Casing t La-Domestic rival O Grave! Pack ❑ Tracy Type of Casing , G ` Specifications ',� rep F1 Public 11C� Y7t 5 Type of GrautA] ? Cl Other C1 Delta Depth of Grout Seal St►P, I I Irrigation 95�Approx. Depth i I Eastern Surface Seal Installed by - Repair Work Done ❑ Type of Pump H P State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth I Filler Material (Below 50') — a TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION i.I DESTRUCTION { I (No septic system permitted if public sewer is l I available within 200 feet.) ' Installation will serve: Residence° Commercial____ Other . , Number of living units: Number of bedrooms Character of soil to a depth of 3 feet-1 Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments I PKG. TREATMENT PLT. 11Method of Disposal Distance to nearest: Well Foundation Property Line 1 LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED LI Distance to nearest: Well Foundation Property Line I SEEPAGE PITS t I Depth + Size Number SUMPS El Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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."Contractor's hiring or sub-contracting signature certifies the following: "Vertify 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 applicant m t call for required�inspe ions. Complete drawing on reverse side. f r Signed X le: DateN FOR DEPA` TMENT USE O /LY 45 Applicatio ccepted by Dated Area / Date�Z Final Inspection by Date` '- Pit Grout spection by - �% t A drlto al�omments: y r ❑ 466-6781 ❑ Lodi 369-3621 ❑ Manteca -7 04 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Se ices 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT-NO. k r-EH 13-21 tREV.I"15Y l EH 14-26 t