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APPLICATION FOR PERMIT .A JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 j 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. L� f ��1�, ` t t. yk� / k i of Sire / �� PM Job Address' cStY Owner's Name Ines es �� + 1+'uNA Address K7�/ /® ►. -- Phone �` ¢ [,( r Contractor �� k <'f Address License No..27✓ ifZFhone y Z TYPE OF WELL/PUMFf. NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ 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 1, ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing ' Specifications f`l Public Ll Other ❑ Delta Depth of Grout Seal Type of Grout I I Irrigation —Approx. Depth l 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 i Depth. Filler Material I Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION l 1 REPAIR/ADDITION DESTRUCTION I I INo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence= Commercial Other Number of living units: Number of bedrooms Y T Character of soil 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 -J-~ 70 Total length/size C3 If FILTER BED ❑ Distance to nearest: Well Foundation °� Property Line SE GE PITS Dpth Size %2 X /4b� Number MP Cl Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that f 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 Healtff 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: "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 applicant must cal or&Jaqyrad in tions. Complete drawing on reverse side, cJ Signed X t Title: Z2 A, Date: F DEPARTMENT USE ONLY Application Accepted byDate Area fl Pit or,Gr6ut Inspection by Date Final Inspection by /Y Date ? 7 �_�7 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 FEf ., .AMOUNT DUE — --AMOUNT REMITTED CK RECEIVED BY DATE PERMIT`NO:-- INFO //'�� CASH t,EH 13-241REV.t/xs7 P. Cy�>�" 3 - p �' rye EH 14.26 ® e7--14 i