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APPLICATION FOR PERMIT 2 � f SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA ' Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED - _ a (Complete in Triplicate) Application is he+eby 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 Di!!stt}rict.G 2 }{ a`, . !- Job Address iJr� J 30 ��,Wit# r -- City ��+ Lot Size&Qye&&U PM t Owner's NameAkkm! ril�k Address S 0 r`r' Phone '7Q ` Contract r ,�� & Address �1�� t License No.r O a`X0Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUG41UN ❑ r PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS r ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation J Dia. of Well Casing ` I El Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications I-I Public F! Other ❑ Delta Depth of Grout Seal Type of Grout _ I 1 Irrigation __Approx, Depth l I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material {top 501 Depth I —Filler I {Below 50'1' TYPE OF SEPTIC WORK: NEW INSTALLATION I] REPAIR ADDITIO .i DESTRUCTION [ I (No septic system permitted if public sewer is I available within 200 feet-) Installation will serve: Residence Commercial_ ther r Number of living units:�Number ae>]eAdr�o�p-ms ^ 0 Character of soil to a depth of,3-feet: ` *� Water table depth L� SEPTIC TANK L7fi Type/Mig Capacity No. Compartments PKG, TREATMENT PLT. Eli, Method of Disposal G Distance to nearestT " Well' -—7 - •"Foun-dafion Property Line E LN. —/ II �o No. & Length of lines t f Total lengthlsize LEACHING LINd FILTER BED w LlDistancefto nearest:,p pWell 2W _,Foundation ►d Property Line SEEPAGE PITS i l 1 Depth Size _ Number.' f SUMPS 0 Distance to nearest: Well Foundation - .-Property Line, DISPOSAL PONDS ` Q. r I hereby certify that I have prepared this application,andthat the work will.be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin"Local.Hgaiiii District. i, 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." Contractors 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." The applicant list call for II re fired inspections. Complete drawing'on revers@ de. A Signed Xl Title:- Date: 4 FOR DEPARTMENT USE ONLY ellidt-7- Application Accepted byQ DateArea f� f Pit or Grout Inspection by Date Final Inspection by Date 1 r Additional Comments: ❑ 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. Box 2009, Stk., CA 95201 I IFEE NFO AMOUNT DUE AMOUNT REMITTED CASH CK RECEIVED BY DATE PERMIT NO. + EH 13.24(REV.1/n 5) �(! EH 14-28 O ,-C'> r