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APPLICATION FOR PERMIT 3" '30 W SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON 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 well/pump and the Rules and Regulations of the San Joaquin Local Health District. ',Job Address City Lot Size -3/d Cr-f - PM Owner's me 'IL��G�1� T}U+S,,35,� Address 4 G Phone qi { Contractor -- Address~ �J License No Phone X TYPE OF WELL/PUMP: t' :NEW WELL ❑ WELL REPLACfMENTo a :DESTRUCTION ❑ ' PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ 'OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK ! SEWER LINES ,ISISPOSAL FLD. ` PROP. LINE s FOUNDATION AGRICULTURE WEOTHER WELL PITS/SUMPS LL= r- INTENDED USE TYPE OF-WELL- -PROBLEM AREA, CON'STRUCTI'ON SPECIFICATIONS j ❑ Industrial LI-Open-Bottom __1❑-Manteca ; Dia. of Well Excavation ' Dia. of W611 Casing ❑ Domestic/Private ❑ Gravel Pack C3 Tracy Type of Casirtig } <_ Specifications F"1 Public 17 Other �' ❑ Delta Depth of Grout Seal Type of Grout i I 1 Irrigation __-.Approx. Depth •-1 1 Eastern �• Surface Seal Installed by _ Repair,Work Done ❑ Type of Pump H.P. State Work Done Well Destruction', 17.) ',,Well Diameter Sealing Material (top 501 fh • t Y Depth rr" Y R •_�- Filler Material (Below 50.1 l� 1 TYPE OF SEPTIC WORK: �NfW.INSTALLATIONA REPAIR/ADDITION I I DESTRUCTION I 1 1No septic system permitted if public sewer is -• �y available within 200 feet) Installation will serve: Residence V1_ Commercial_ Other Number of living units: A— Nunhber of bedr oms Character of soil to a depth of 3.1" Water table depth SEPTIC TAMC ¢Type/Mfg Capacity�� No. Compartments PKG. TREATMENT PLT. ❑ �' 'b+'!' IF rMethod of Disposal Distance to'nearest: Well 'Foundation< Property Line 40 i LEACHING LINE ( No. & Length of lines, — Total length/size FILTER BED ❑ Distance to nearest: Well IF Foundation '� Property Line SEEPAGE PITS .1 ! Depth " Size , Number SUMPS Ll Distance to nearest: ; Well Foundation t 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 Diltrict. Home owner or licensed agent's signature certifies the following: "l 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." ,r.--.----- The applicant ust call far a1 d inspec ns. Compl to drawing on r verse side. r N Title: r Date: F. DEPARTMENT USE ONLY ll1ly , Application Accepted byT C..,�� ,� Date ��` Z- Area Pit or Grout Inspection by Date Final lnspe ion by Date Z Additional Comments: ❑ Stk 466-6781 ❑ Lodi 1 ❑ Mint 823-7104 ❑ Tracy 635-6385 Applicant- Return all copieto: it mental H Ith Permit/Services 1601 Ave P.O. Box 2009, Stk. 95201 INFO AMOUNT bUE AMOU T REMITTED CASH ECEIVED BY DATE PERMIT'NO. CK FEEY +.EH13-24 1REV.i i a 5; e- �—a `0Z) EH 14-26 R I I ii 14 I