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4a 3Y APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA I Telephone (209) 466-6781,_ PERMIT EXPIRES 1-YEAR FROM DTE: ISSUED` (Complete in Triplicate) no.f -Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work`hi:rein 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. r -i c r , *taV L.ay � ' ICES Job Address .City FE 'Lot Size PM r1 flwnar'. 21ALt Address /;Pgo .. City TYPE OF WELL/PUMP: NEW WELL 11 WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑N" SYSTEM REPAIR p' 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 If Manteca Dia, of Well Excavation Dia. of Well Casing P01150mestic/Private ❑ Gravel Pack = ❑ Tracy Type of Casing Specifications M Public i 1 Other !'f,<❑ Delta Depth of Grout Sfeal Type of Grout I I Irrigation , _.-Approx. Deptli I I Eastern Surface Seal Installed by _ t Repair-Work Done IV Type of Pump= — H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 t c Depth s Filler Material (Below 501 ' TYPE OF SEPTIC WORK: NEW INSTALLATION-1`l REPAIR/ADDITION I DESTRUCTION I I INo septic system permitted if public sewer is i ( I available within 200 feet.l Installation will serve: Residence Commercial,_k- Other Number of living units: Number of bedrooms # 4 - Character of soil to a depth of 3 feet: Water table depth r/~" SEPTIC TANK ❑ Type/Mfg r Capacity s No. Compartments PKG. TREATMENT PLT. ❑ 1 ._.- -�# -� _. �.� - ,. - � V•------- – – •,� � .,. .._-N Method of Disposal w Distance to nearest: Well Foundation r Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line ew 6 ' SEEPAGE PITS 11 Depth Size T Number SUMPS L� Distance to nearest: Well Foundation r + Property Line I DISPOSAL PONDS El " 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 ust all for all required inspections. Complete drawing on reverse side. Signed X Title: Date: -0 0 f FOR DErpARTME T USE ONLY Application Accepted by Date Area Pit or Grout Inspection by Date Final Inspection by __—'Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 E Applicant - Return all copies to: Environmental Health Permit/Services'1601 E. Hazelton Ave., P.O. Bax 2009,--Stk., CA 95201FEE r INFO /{AMOUNT DUE AMOUNT REMITTED LASH RECEIVED BY DATE PERMIT NO. + EH 13.24 1REV.I/N 5) EH 14-26 //!{