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-7 &U , #4W4t 110 O APPLICATION FOR PERMIT r--% 4 SAN JOAQUIN LOCAL HEALTH DISTRICT D5(�;� , 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 DEC 17 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) ENVIROMENTAL HEALTH � Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the wo}kkMWA IQUapplication is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1662 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. 1 1 SID f� f Job Address � City �.� Lot Size PM - J120 N �t s Owner's Name Ca.�fras-1s Address 9561 'f Phone (32 ✓ Contractor Address ~T 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 ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications F1 Public ❑ Other 71 Delta Depth of Grout Seal Type of Grout 1 1 Irrigation —.Approx. Depth I I Eastern Surface Seal Installed by _ Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material Itop 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION REPAiRIADDITION ( I DESTRUCTION I I (No septic system permitted if public sewer is available yvithin 200 feet.( If n 1 Installation will serve: Residence_ Commercial— Other �e � i e'�to — �Otv Number of living units: Number of bedrooms l f Character of soil to a depth of 3 feet: S44 C6Y »+161IX _W1 or9dh+�-5 Water table depth SEPTIC TANK ❑ Type/Mfg I Capacity "f Jr No. Compartments o2 PKG. TREATMENT PLT. ❑ Method of Disposal �—fA , F)eQ Distance to nearest: Well rFoundation Property Line eo LEACHING LINE C�No. & Length of lines ) 1;11e_ Total length/size t7 i'�• �G FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS ❑ Diannearest: 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." The applican must call f r all requ'eI in ctions. Complete drawing on rre��v��e��r��se side. 1 �j Signal X Title: c /E'/l114/ �� y �h Date: �� U • FOR DEPARTMENT USE ONLY Q Application Accepted by Date 1! * '� Area Pit or Grout InspectiA. ' y Date Final Inspection by Date o Additional Comment +M.. ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environme t Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Silk., CA 95201 IFEENFO Aiv10UNT DUE AMOUNT REMITTED CK RECEIVED BY BATE PERMI7 N0. 4Z;?v 1*, ,, , + EH13-24(REV. /e sl EH 14-2e