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' APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT ' a . 1601 E. WAZEL i ON AVE:, STOCKTON, CA Telephone (209) 466-fi781', . PERMIT EXPIRES 1 YEAR FROM,.bATE ISSUED r IComplete�,in 'Triplidrrj, Application is hereby made to the San Joaquin Local Health District for a perrriil tor_gpnstrLci and/or install the work herein described. This application is r made in compliance with San Joaquin Cou,ky Ordinance No.549 for sewage or' o' r 862 for Well/pump and the Rules and Regulations of the San Joaquin Local Health District. A 70` � Lit City �Ld'kllf✓ku �� Ll_J��- / Job Address Lot Size PM r ,J Owner's Name Address-ai' - C Phone fA - - - Corstractor..Uf Ll t°V_1D - n Address J rid ` License No.`v� � � Phone TYPE OVMCLTPUIVIP: NEW WELL ❑ WELL REPLACEMENT D. DEST_RUCTION`S PUMP INSTALLATION`❑ SYSTEM REPAIR ❑ OTHER ❑` DISTANCE TO NEAREST: SEPTIC TANK - L_ 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 We Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑`Tracy'-r Type of Casing Specifications F] Public 1-1 Other FI Delta Depth of Grout Seal Type of Grout I I Irrigation _Approx. Depth I I Eastern Surface Seal Installed-by t '�' y Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material atop 50') I Depth Filler Material (Below 50'1 - TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION l I DESTRUCTION l I INo septic system permitted if public sewer is J available within 200 feet.) Installation,will serve: Residence Commercial Other ` �' Numtier of living units: ' i- Number of Character of soll to a depth of 3.feet: Water table depth A L�Q SEPTIC TANK P ' Type/Mfg IVXi Capacity-1(912-0- No. Compartments z PKG. TREATMENT PLT. ❑ * f t Method of Disposal Distance to nearest: Well 1 0 Foundation 10 Property Line Q� (� LEACHING,LINE lV y No- & Length of lines _ t-�f ;�^� Total lengthisize ©t x a I FILTER BED B11,Distance to nearest: Well O G' Foundation i o Property line ` y SEEPAGE PITS 'Depth tJ(s- Size _ Number�:J r --- SUMPS Distance to nearest: Well C Foundation—1.0 Property Line DISPOSAL PONDS hereby certify that I hav +repared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and t rules and regulations of "San`Joaquin Local Health Di§trict. Home owner or licensed a,�ent's signature certifies the following: "I certify that in the-p@rformance of the work for which this permit is issued, I shall not employ any person in such mariher.as to become subject to workman's compensation laws$f-California."Contractof'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 persoris subject to workman's compensa- tion laws of California." _ The applicant m t call for re ired inspections. Complete drawing on reverse side., Signed P Title-0d Rate: -1—LA t? r FOIA DEPARTMENT-USE ONLY Application Accepted by -' u Date I&— Area or Grout Inspection by ate 6`' Final lnspectian-by Date Additional Comments: 0 Stk 466-6781 ❑ Lodi 369-3621 CI Manteca 823-7104 E]-Tracy; 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave-, P.O, Box 2009, Stk., CA 95201 r FEE INFO AMOUNT DUE AMOUNT REMITTED CASH 'RECEIVEd BY DATE PERMIT'NO. +.EH 13-24(REv.1 Hs) EH 14-28 �� s /ti g 1S TO"7—�