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s APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON 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 well/pump and the Rules and Regulations of the San Joaquin Local Health District. 1315 A 330/ Job Address 2 A City f Lot Size 6i9e PM q © � ® , /l[�) Address �J d} �' "� Phone 36 irq ry Owner's Name--- � _ �� -----�- -�-e 2P r Utz Contractor Q d e 1ci-I Address License No. Phone _ 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 FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA,. CONSTRUCTION SPECIFICATIONS � ❑ Industrial ElOpen Bottom LJManteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Typefiof Casing Specifications f'l Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout I I irrigation --Approx. Depth I I Eastern Surface Seal Installed by I - * tf , Repair Work Done ❑ Type of Pump H.P. � State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 I Depth Filler Material (Below 50') I a TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIRIADDITION i I DESTRUCTION 111No'septic system permitted if public sewer is ` available within 200 feet.). Installation'will serve: Residence Commercial Other Number of living units: —I-- Number bedrooms /^Character of soil to a depth of 3 feet: CL LoA'", _ Water fable depth 1)' �pI#D"�"INo.Com artments SEPTIC(TANK i Type/Mfg �Capacii s j q PKG. TREATMENT PLT. ❑ .Method of Disposal I Distance to nearest: Well Foundation=7�®r Property Line q1_90_r LEACHING LINE LP- No. & Length of linesq0 Total length/size 0 FILTER BED ❑ Distance to nearest: Well t 101 �C Foundation� Property Line f f ` A. ----^ -1 � f SEEPAGE PITS 1'r Depth Size — Number SUMPS ❑ Distance to nearest:-ri,� 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 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." k The applicant ust call for all r quired inspections. Complete drawing on reverse side. Signed X Title: Ar Date: FOR DEPARTMENT USE ONLY Application Accepted by Date 2'P Area 4 t Pit or Grout Inspection by Date Final Inspection by I � 9 Additional Comments: ❑ Stk 6-6781 D Lodi 369-3621 ❑ fVfenteca 823-7144"�'�O Tracy 335-6385`. _� Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazalton Ave., P.O. Box 2009, Stk., CA 95201 7 FEE AMOUNT DUE AMOUNT REMITTED ASH RECEIVED BY DATE PERmir'NO. INFO C], ♦ EH 13-24 IREV.1/R 5t �� ,« �J 27 EH 14-28