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a i APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES TYEAR FROM DATE ISSUED (Complete in Triplicate) I 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 � � Jam' 'C-,+ City Lot Size PM Ow is Name fidress / f Phone 9-4 p q antra o v License No. 1 Phone L TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLA04MENT ❑ DESTRUCTION ❑ PUMP INSTALLATION SYSTEM.REPAIR ❑ OTHER ❑ DISTANCE TO NEARES7:TSEPTIC TANK - SEWER.LINES DISPOSALFLD. PROP._LINE t FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELT— PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom " *F N❑ Manteca Dia. of Well Excavation Dia. of Well Casing a ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy -k. Type of Casing Specifications I'] Public ❑ Other ❑ Delta ,}"!Depth of Grout Seal Type of Grout i ><rrigation _.-Approx. Dep1h i ast rn urface Seal Installed by Repair Work Done ❑ Type of Pum H.P, State Work Done_ I Well Destruction ❑ Well Diameter } 7 AV _,_ ._--- Sealing Material flop 50'1 i Depth /i Filler Material (Below 501 _ TYPE OF SEPTIC WORK: NEW INSTALLATION l 1 REPAIR)ADDITION l I DESTRUCTION i I (No septic system permitted if public sewer is 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: 4 Water table depth SEPTIC TANK ❑ Type/Mfg I Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal ; Distance to nearest: Well Foundation Property Line ' LEACHING LINE s ❑ No. & Length of lines Total length/size r FILTER BED' " ❑ Distance to nearest: Well Foundation Property Line I SEEPAGE PITS , I i Depth I Size Number SUMPS f - Ll Distance to nearest: Well Foundation Property Line h 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, 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 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 applican V194t cal uired inspections. Complete drawing on raver ide. F 79 Signe Title: Date: F_OR DEPARTMENT USE ONLY Application Accepted by Av� Date Area Pit or Grout Inspection by Date Final Inspection by Date a a Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-36211 ❑ Manteca a23-7104 © Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED I CK 4 INFO CASH RECEIVED BY DATE PERMIT N0. .,EH13-24 iHEV.1 i a 57 EH 14-26 / / +7 0