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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE i ON 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. 1662 for well/pump and the Rules and Regulations of the San Joaquin Local Health Dist<ictt. a s DGf C� e!t4 PM 1 City of Size I Jab Address � Owner's Name �.-AeL .- ievA Address Contractor Address ` License No.629?9r�Phone TYPE OF WELL/ NEW WELL J< WELL REPLACEMENT ❑ DESTRUCTION ❑ a PUMP INSTALLATION ❑ SYSTEM-REPAIR r❑ _ ate" ---- OTHER`❑"""`�'"""` g°°�' ,� {/� DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. "PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL 1--`PITS/SUMPS t INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS j "14ti VVV L7 Industrial ❑ Open Bottom Cl Manteca Dia. of Well Excavation Dia.1of Wel! Casing Domestic/Private ravel Pack ❑ Tracy Type of Casing Pi Specilica'tions f"I Public I] Other C1 Delta Depth of Grout Seal * Type of Grout I i Irrigation —,.Approx. Depth l I Eastern Surface Seal Installed by - Repair Work Done 0 Type of Pump H.P. 173 State Work Done 4 Well Destruction ❑ Well Diameter _�_.._ Sealing Material (top 50') I Depth 2'ro Filler Material (Below 50') 9244 — TYPE OF SEPTIC WORK: NEW INSTALLATION (1 REPAIR/ADDITION l I DESTRUCTION I 1 (No septic system permitted if public sewer is I available within 200 feet.) t [ Cr Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal j Distance to nearest: Well Foundation Property Line i f { I LEACHING LINE ❑ No. & Length of lines Total length/size I ` FILTER BED ❑ Distance to nearest: Well Foundation Property Line i x SEEPAGE PITS I 1 Depth Size — Number ' w SUMPS Ll Distance to nearest: Well Foundation Property Line 1 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. f 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-coritracting 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." I I The applicant must call for all required inspections. Complete rawing on reverse side. 1 1 i Signed X_s�i _�,, Title: Date: FOR DEPARTMENT USE ONLY �"�, j� 'I Application Accepted byVA Date \,,,~ `-'� «, Area Pit or Grout Inspection by Date t Final Inspection byGate Additional Comments: i ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca,_,823-.7,1.04s.••._,,,C7TracYy_.835-W5 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009Stk., CA 95201` - \�.' �r,�a�..._....,.....,......_...�....Y.�,�..,.w.�.� �....,.......... VRA. FEE AMOUNT DUE AMOUNT REMITTED CK FI RECEIVED BY DATE PERMI7'NO. INFO r.EH13-24 41REV.1/851 \c_1lu� -r' / 14 EH 14-2e ro r