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I 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 ' (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 welt/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address �r City Lot Size PM Owner's Name /epi X /fS�i GrFjV Th,. , :.* t Address ✓r/q Phone Contractor IV VA- SvN Address'r�0�. L ucd �.,� ��; � - License No. :phone TYPE OF W LL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTIOTN PUMP INSTALLATION ❑ y SYSTEM REPAIR ❑ OTHE4. DISTANCE T;0 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` Ll Industrial ❑ Open Bottom ❑ Manteca ---ia. of Well Excavation / ❑ Domestic/Private ❑ Gravel Pack Dia. of Well Casing ❑ Tracy Type of Casing ❑ Public�_,..-�. ❑ Other �Specifications ❑ Delta Depth of GroutSealIrrigation _gpprox Depths of Grout y ng"- ❑=Eastern Surface Seal Installdd-ny-�- Repair Work Done ❑ Type of Pump )r StH.P. t} t ` ate Work Done i Well Destruction ❑ Well Diameter Sealing Material{top 501)�- �- -+ I 1 Depth ) Filler-Material (Below 501) I TYPE OF SEPTIC-WORK: NEW INSTALLATION ❑ REPAIR/ADDITION DESTRUCTION ❑ (No septic system permitted if public sewer is r 1 .,„ ' _ .x available within 200 feet.) Installation will "serve: Residence Commercial Other Number of living units: _�_ -Numberppaf bedrooms -7- t-� I " Character of soil to a depth of 3 feet oh/s'Ic _ SEPTIC TANK I. LL Water table depth. --wW---. ❑ TYPe/Mfg Capacity �12°i:t No. Compartments PKG, TREATMENT PLT. ❑ k Method of Disposal Distance to clearest: Well SOD• Foundation 1 Property Line LEACHING LINE 4 ❑ No. & Length of lines r Tota n FILTER BED "'-�„. '.' gth/size ❑ Distance to nearest: _.--Welt Foundation i I Property Line j SEEPAGE,PITS It Depth /d ' ._Size - X /S "ui Numb.eert r = I k , --� SUMPS ❑ Distance toynearest:- Well Foundation roperty Line Oo' � DISPOSAL PONDS ❑ I hceteby certify that I have prepared this application and that the work will be done in accordance with'San Joaquin countyfordinartces, state laws, and rules' and regulations of the San Joaquin Local Health District. ` Home owner or licensed-agent's signature certifies the following: r employ an �- 1 9: "I certify that in the performance of the work for which this permit is issued, I shall not P Y y person in such manner as to-become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature . Q6 certifies the following: "I certify that in the.Performance of the work•fvr-which this i_s issued, shalf-emplo"y persons subject to workman's cvmpensa 1 tion laws of California." r l - / " �. The applicant must Sall for all required'inspections. Complete drawing on reverse side. > Signed Title: Date: 42 /, 4r ` F,OR DEPARTMENT USE ONLY b Application Accepted by /v Date i Area Pit or Grout Inspection by ! Date Fina! Inspection by Date i Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-382!11 ❑ Manteca 823-7104 ❑.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 r INFO CASH RECEIVED BY DATE PERMiT'NO. + EH13-24.REV,i/85) © a0 EH 14-26 „