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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT t 1601 E. HAZELTON 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. Si h ✓ d, Job Address � �� m City 6 kPIZ Lot Size 7e7PM c Owner's Name-T,• W. sdw Address � � �v �' dot��Phone 1' .Contractors ti - "'t' Addres5� ` '+Y License No.�3 Phone TYPE OF WELL/ NEW WELL ❑ WELL REPLACEMENT ❑ 3 DESTRUCTION ❑'i --` INSTALLATION ❑ SYSTEM REPAIR 4 OTHER ❑§ DISTANCE TO NEAREST:,SEPTIC TANK # SEWER LINES ! " .DIS AL FLD.3` PROP. LINE FOUNDATION Tom- .'ry'^ AGRICULTURE WELL THER WELL PITS/SUMPS INTENDED USE, , TYPE OF WELL PROB REA CONSTRU N SPECIFICATIONS ❑ Industrial'. ' ❑ Qpen Bottom ' .❑ Manteca of'Well Excavation Dia. of Well Casing .- x ❑ Domestic/Private �❑ Gravel Pack- v ❑ Tracy Type of Specifications ❑ Public ` ❑ Other - *--.. _E] Delta st. a+, � Depth of Grout`Seal Type of Grout ❑ Irrigation 4 ` _�pprox. Depth 4❑Eastern Surface Seal Installed by' Repair Work Done 11-1 Type,of Pump} i ,H.P. _ State Work Done Well Destruction: ❑ Well Diameter a "` 'Sealing-Maierial atop 501 f r Depth "' '# j FillerrMaterial Melow 501 r' ' TYPE OF SEPTIC:WORK: NEW INSTALLATION o REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is ! available within 200 feet.) UJ Installation will serve: Residence Commercial_ Other Number of living units:— Numberr of bedI oomstx - Character of soil to a depth of-3.feet: "� / 3 Water"table depth SEPTIC TANK ;>e,, Typ61Mfg apacitV" t No. Compartments PKG. TREATMENT PLT. ❑ r �`��Y �p ! — /.-" Method of Dispo aI ` 1 f Distance to nearest: Well Foundation _ T Property Line AP/6 a L. LEACHING LINE No. & Length of lines G110 ki IAI4 5 Total length/size t FILTER BEb A; k, ❑ Distance to nearest: . 'I Well✓00,F'0 + Foundation_/— Property Line SEEPAGE PITS ❑ Depth i _ Size Nymber SUMPS Distance to nearest: Well - Foundation 40?t_ Property Line DISPOSAL PONDS ❑ 3 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. 1 1 I 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 applicant must call for all required inspections. Complete drawing on reverse side. J Signed X_ \P1a.ILA Title: a ZpJAv t"r Date: I FOR DEPARTMENT USE ONLY Application Accepted by Date 3 Area 01 Pit or Grout Inspection Date Final Inspection by Date v Additional Comments: 6411PUH-¢f'r1 Pl 61, f'sir, �, e P f G Jen --d i-. ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Menteca; .823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental HeaI6 Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. INFO CASH —+EH14fREV.,%asl -. # r EH 1428 Y- —7S