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fes: APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA it Telephone 42091 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 Aules and Regulations of the San Joaquin Local Health District. ; I Job Address w /� / 7 City GO 0/1 Lot Size 2 Gt /�S PM Owner's Named �iY/'�IGI Address / E� 3`1 v 7r7. 1/.4. Phone Contractor Address ! License No. Phone TYPE OF WELL/PUMP: " NEW WELL LJWELL REPLACEMENT EJ° PUMP INSTALLATION ❑ DESTRUCTION LJ - 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 ❑ Domestic/Private ❑ Gravel Pack Dia. of Well Excavation Dia. of Well Casing ❑ Tracy Type of Casing F] Public ❑ Other Specifications CI Delta Depth of Grout Seal i I Irrigation — '-Approx. Depth I 1 Eastern TYPe of Grout Surface Seal Installed by Repair Work Done ❑ Type of Pump H P - Well Destruction E2Well Diameter State Work Done Sealing Material (top 50') Depth Filler Material (Below 50') TYPE OF SEPTIC.WORK; NEW INSTALLATION I 1 REPAIR/ADDITION l4' DESTRUCTION*)'-INo:septic system permitted if public sewer is r i Installation will serve: Residence Commercial_ Other available within 200 feet.) Number of living units: _ Number of bedrooms f � I Character of soil to a depth of 3 feet: s-,",of 7m-/ e SEPTIC TANK Type/Mfg Water table depth ,S -41' ❑ G�Gr>� ��j�f PKG. TREATMENT PLT. F1 Capacity- No. Compartments Z Method of Disposal r {' Distance to nearest: Well `� Foundation 15' .�,/ , Property Line LEACHING LINE Yet No. & Length of lines 0 FILTER BED Total length/size ❑ Distance to nearest: WellFoundation _., Property Line SEEPAGE PITS I i Depth Size SUMPS Number 3 Distance to nearest: W02,� 1 L 0 Foundation Property Line i DISPOSAL PONDS ❑ i� � 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin count ordinances, state laws, and ; rules and regulations of the San Joaquin Local Health District. q Y 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 subiect 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, tion laws of California." I shall employ persons subject to workman's compensa- The applicant PlIst call for all required ins ction Complete drawing on reverse side. Signed X 6 tela: +�'t-c�.c�t,� •!'r '—'.�i�'"�p Date: FOR DEPARTMENT USE ONLY Application Accepted by I Date Area / Pit or Grout Inspection by ` Date U �`_ Final Inspectionfi -�, Date Additional Comments: !� - v+ -- ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O, Bax 2009, Stk., CA 95201 " e r EINFO AMOUNT DUE AMOUNT REMITTED RECEIVED 6Y DATE PERMIT N0. EH 13-24(REV.1 n WEH 10-26 - ,