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APPLICATION FOR PERMIT 4 r SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 7 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health Disfrict 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. �)��,, I Job Address Z,Z �y5, . le-k FCI', City '^0d/, 'Lot Size PM Owner's Name _— � C Phonnee Address 7�b +� � 75� J �� a .fid Contractor Address License No. / Phone C. TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ maiiBt*?11 PUMP INSTALLATION ElSYSTEM REPAIR ElOTHER J0, i✓ ' 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 ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Welt Excavation MAIL Dia. of Well Casing ❑ Domestic/Private L2 Gravel Pack `? ❑ Tracy r Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal '46 JF•b Std . Type of Grout6me ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done �a Well Diameter Sealing Material (top_50') Depth Filler Material {Below 501 TYPE OF SEPTIC ORK: NEW INSTALLATION ❑ REPAIR/ADDITION DESTRUCTION © (No septic system permitted if public sewer is { available within 200 feet.) Installation will serve: Residence— Commercial Other r. Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK •© T e/Mf Yp 9 _ Capacity No. Compartments PKG. TREATMENT PLT, ❑ 4 Method of Disposal Distance to nearest: Well Foundation Property Line i LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well-° Foundation Property Line I SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line 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 I 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 CAfornia." The applicant. u call fo a requi in S. Complete drawing on, rse side.- , r I Signed ' y Title:_ v� t t Date: O E T t _ � _ SE ONLY Application Accepted by Date / /�—" Area Pit or Grout Ins ti by Alor 6 Ll2 r Date Final Inspection by S F Date l � 9 = Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-63135` ;2�5, 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 COK RECEIVED BY DATE PERMIT"NO. INFO i + EH13-241REV.t/e 51 x�d-� `�r� t M SI EH 14-28 �/ ca 1 t7