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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, p d� N. ecarl R1�. Aca r1A City 4 0 Lot Size /`Yr_--- PM Job Address �, q 411 5 too W X Owner's Name o�.d Do6res l DrkAddress W1'9g r8ear! Rd' Phone ct-IF Zq 1 044" lr 2 �q� Nr P�iQr'� f�R^ License No. Phone,�q"$24 I Contractor 561 A e s TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT •❑ - DESTRUCTION ❑ PUMP INSTALLATION C SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST; SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia of Well Casing 4:dustr,_,tol Open Bottom ❑ Manteca Dia. of Well ExcavationSpecifications meiclPrivate ❑ Gravel Pack ❑ Tracy Type of Casing Type of Grout n Public n Other ❑ Delta Depth of Grout Seal p I I Irrigation ---Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction D Well Diameter Sealing Material (top 501 O Depth Filler Material (Below 501 -- r TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION I 1 DESTRUCTION I I (No septic thine200 fee�t�ed if public sewer is V i ` Installation will serve: Residence_X Commercial— Other Number of living units: Number of bedrooms Character of soil m a depth of 3 feet: J,� �y Water table depth SEPTIC TANK ❑ Type/Mfg rn r-e ZS+ Capacity_)_q� No. Compartments \CJI PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest; Well 30' Foundation Property Line LEACHING LINE ❑ No. & Length of lines ~ It Total length/size 0 FILTER BED ❑ Distance to nearest: Well /SSD Foundation_-_�____ Property Line SEEPAGE PITS { I Depth Size_ _ Number —� SUMPS L Distance to nearest: Well &U 12Foundation Property Linery� r 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, an rules and regulations of the San Joaquin Local Health DiMrict. 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 th 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 c r al inspections. Complete drawing on reverse side. A iTitle: ` Date: Signed F R DEPARTMENT USE ONLY qff i Application Accepted by Date Area Pit or Grout Inspection b Date Final Inspe�.by Date / r Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 O Tracy-835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 t FEE AMOUNT DUE AMOUNT REMITTED ASR RECEIVED BY DATE PERMIT NO. IN J(�/�j (��{�+ (r(/A I ♦.EH 13.241REV. /nsl �'��' (f 7(f / ^��( EH 14-26