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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..1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address ..�C �CO�I� / ll�!/'l.t) 1+�r City._ _[�� Lot Sized PM Owner's Name {/IL� Address A"" Z. AV—.— PAY Phone Contractor 41 •wlLl ,, Address License Noor�c],AoG Phone TYPE OF WELL/PUMP: NEW WELL 0 WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WE\C- --- OTfEER-WELL "1- PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial C'Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing t . ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy_ Type of Casing Specifications € 17 Public Cl Other F1 Delta Depth of Grout Seal Type ype of Grout I I Irrigation _._Approx. Depth l l Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material Itop 501 Depth r- Filler Material (Below 501 -. .. TYPE OF SEPTIC WORK: NEW INSTAL"L'A_TION REPAIR/ADDITION l I DESTRUCTION( I (No septic system permitted if public sewer is t ; ' available within 200 feet.l Installation will serve: Residence Commercial_ Other t f Number of living units: � Number of.bedrooms =%:�r r `. x Character of soil to a depth of 3 fe t ' 4 Water table depth SEPTIC TANK1 Type/Mfg`•.f,. Capacity No. Compartments PKG. TREATMENT PLT. ❑ -+ *`t i Method of Disposal �—+ Distance to nearest: 'Well Foundation 0 Property Line LEACHING LINE #' No."& Length of linesTotal length/size .� I FILTER BED ❑ Distan-c to,nearest: Well Foundation Property Line ) /O(J SEEPAGE PITS 11 Depth ' Size Number f SUMPS ❑ Distance to nearest: Well _,Foundation 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 District. - Home owner or licensed agent's signature certifies-the.following: 71 certify that tiin�the performance of the work for which this permit is issued, I shall not employ any person in such manner as to become subi ct to workman's compensation laws of California." Contractors hiring or sub-contracting signature certifies the following: "I certify that in the performance ofthe work for which this permit is issued, l shall employ persons subject to workman's compensa- tion laws of California." x. %, The applicant must tail for II requir d inspections. Complete.drawing on reverse side. Signed X A� t,.. ` Title: � � . R — Date: H t FDR DEP RTMENT USE ONLY - !"'+. Application A—ccepted by - Date r v Area -•w rt' r Grout Inspectiontl - Date Final Inspection by ate Additional Comments: V _ ❑ Stk 466.6781 ❑ Lodi 369-3621 MantecaN.823-7104 -L] Tracy,835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA'95261 INFO -AMOUNT-DUE-- �� AMOUNT REMITTED ;CASH x —RECEIVED BY--,- DATE PERMIT'NO. i.EH 13-24(REV.I/a 5) EH 14-26 �/►S `/./ 1 - f