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T. 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 RECEIVER (Complete in Triplicate) CC{� Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the worDFICin de&riJ9&9rhis application is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump art ,(hgl�i l dd Req la^on u heSanJoaquin Local Health District. CIVVr II1L HEALTH (� s PERMIT/SERVICES Job Address d 1 ^� __ City �" Lot Size PM Owner's Name h J .f�� /el--Ce�'1, Address Q(D 7 1 LCL Xt ifZ/1 Phone T W l L Contractor!�r..e Address License NoS, 3 Ph,ne TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER-LINES' p DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑-Domestic/Private ❑ Gravel Pack . ❑ Tracy Type of Casing Specifications �� 171 Delta Depth of Grout Seal Type of Grout _ I I Irrigation _ Approx.[D, th I I EasternF1 Public rl OtherV_- Surface Seal Installed by _ Repair Work Done 1 -tJ Type of Pump ...___. H.P, �- State Work Done ' Well Destruction ❑ Well Diameter Sealing Material (top 50') r e _ - Depth i Filler Material (Below 50') -J_ TYPE OF SEPTIC WORK: , NEW INSTALLATION I 1 1 REPAIR/ADDITION I I DESTRUCTION I I Mo septic system permitted it public sewer is 1 r"'`" i I available within 200 feet.] Installation will serve: Residence' Commercial_ Other O Number of living units: Number of bedrooms 6 Character of soil to a depth of 3 feet: t.' Water table depth SEPTIC TANK ❑ Type/Mfg, j Capacity No. Compartments PKG. TREATMENT PLT. ❑ - ; Method of Disposal Distance to nearest $� Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED C]~ Distance to-nearest:— 'jWe11- ----w---Ft�undati Pe57ty Line"' SEEPAGE PITS i I Depth I I Size' Number i SUMPS D Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I , 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 Joaquiri 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." 11 The applican ust c II for all [e (red inspections. Complete drawing on reverse side. / Signed X Title: ` Date: _l /'r/ Q'k? FOR DEPARTMENT USE ONLY //Z Application Accepted by Date Area Pit or Grout Inspection by ` Date Final Inspection by Date 7 � e 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 2409, Stk., CA 95201 FEE INFO AMOUNT DUE j AMOUNT REMITTED GASH RECEIVED BY DATE PERMIT NO. +.EH 13-24(REV.t/B51 EH 14-28