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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON 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 welllpump and the Rules and Regulations of the San Joaquin Local Health District. } Job Address _ `� `�.d.4, City LotSize_S � PM Owner's Name," l Address S�> S• -A .t& Phone -_z_-�,Li' S r P O '�]" -167 E ( Cd Phone i2 -S%6S Contract Address License No. o TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE r FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS v, t INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS { ❑ Industrial I].Open Bottom ❑ Manteca Dia. of Well Excavation_ _ Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications 17 Public ❑ Other ��❑.Delfa Qepth of Grout Seal `� Type of Grout �- " 1 Irrigation ___Approx. Depth, I 1 Eastern _Surface Seal Installed by ?� 4 Repair Work Done ❑ Type of Pump H.P. P -r State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50'1 y Depth ,Filler Material (Below 501 - TYPE OF SEPTIC WORK: NEW INSTALLATION RE-PAIR/ADDITION I,] DESTRUCTION-1-I'IN o.septic'system permitted if public sewer is f J Ile k r available within 200 feet.) I Installation will serve: ResidenceCommercial— Other Number of living units: Number of bedroom§ Character of soil to a depth of 3 feet: '' Water table depth SEPTIC TANK Wr Type/Mfg ` ; 2 Capacity__.I No. Compartments PKG. TREATMENT PLT, ❑ r f 4 7 Method of Disposal Distance to nearest: ,Well `RFo ndation ti 0 Property Line. LEACHING LINE No. & Length of lines -'�' -- •� '--t Total length/size Qnx FILTER BED ❑ Distance to nearest: Well 56 Foundation to Property Line s SEEPAGE PITS Itr"'Depth Size ' 33 ' ' Number 3 SUMPS ❑ Distance to nearest: Well I 0Foundation 10 Property Line—5_ I DISPOSAL PONDS 0�... 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 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:"I certify that in tK6 performance of the work for which this permit is issued,1 shall employ persons subject to workman's compensa- tion laws of California." The applicant mu call for' Ili quired inspections. Complete drawing on reverse�jde. 11�� pp Signed X Title: Date: 17_ _,07 POR bEPAR`fMENT USE ONLY Application Accepted by ,r s' Data � AArea } P..iCor Grout Inspection by Date % Final Inspection by Dat+ 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 ASH CK 4 RECEIVED BY DATE PERMIT�NO. + EH 13-241REV.finsY /t 7�nf EH 14-20 C.! / 4L`�