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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1=YEAR FROM DATE ISSUED s . (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 Gity �-�- Lot Size PM Owner's Name I f Address (. 25, t`-9/M O[ CI[-i S Phone �3 Contractor v2 r tJ[L L•%IP Address CJr /jf rl ^01Tt°&License No., 25 �Phone e TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ I 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 •❑ Industrial ❑ Open Bottom ❑`Manteca-- w'"Dia.of"Well El(EaVation--'-- --"— ""-Dia'-of-Well-Casing�:, ❑ Domestic/Private ❑ Gravel Pack ❑•Tracy Type of Casing Specifications { I (1 Public i=1 Other ;F C1 Delta Depth of Grout Seal Type of Grout i�I Irrigation _Approx. Depth i I Eastern Surface Seal Installed by s r " Repair Work Done ❑ Type of Pump H.P.r State Work Done' Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth # Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION [.1 REPAIR/ADDITION)( DESTRUCTION l 1 Wo septic system permitted if public`sewer is J� , t available within 200 feet.) I i Installation will se4: 'f Residence "' Commercial Other ` f' Number of living units: Number of bedrooms �, i Character of soil to#a depth of 3 feet: q {� L= _-_ Water table depth SEPTIC TANK" ` LIType/MfgCapacity No. Compartments F PKG. TREATMENT PLT'.'❑ " �.. Method of Disposal I ' L 1 j Distance,to nearest: Well Foundation Property Line LEACHING LINE •; � No. Length of lines d Total length/size CY 6 J5 77 FILTER BED I Distance to nearest: Well __/ Foundation 7— Property Line-I!& J= f SEEPAGE PITS � I'] Depth nt, `" Size `. Number -SUMPS—, ❑ Distance to nearest: Well Foundation Property Line �+ DISPOSAL PONDS ❑ a 3 r lihereby 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. A- t Home,��,IIowner 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 emplfiy any person?in such menner 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- tionlaws of California." The applicant mus[cat)fora required inspections. Complete drawing on reverse side. Signed a4 Title + f Date: a .� FOR DEPARTMENT USE ONLY i Application Accepted by Date 7 Area Pit or Grout Inspection by 6 Date Final Inspection by Date. ! e Additional Comments: s L] Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Heatth Permit/Services 1601 E. Hazalton Ave., P.O. Box 2009, Stk., CA 95201 FEE 'INFO AMOUNT-DUE.,., AMPOUNTEMITTED, 'C SH ~ RECEIVED-BYDATE "PERMIT'NO. +',EH 13-24 4REV.,i n sl EH 14-26 JJJ .