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APPLICATION FOR PERMITQ�� i SAN JOAQUIN LOCAL HEALTH DISTRICT C —1 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES I'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 a pplication - r^t:made,in compliance with.San Joaquin County Qrdinance 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 /'d Lot Size PM Owner's Name _/j L ahld 10 �� W Address k /G Phone Contractor "10 6 d LL1'Z1A dress S rLicense No, Phone TYPE OF WELL/PUMP: NEW WELL~,j —WELL REPLACEMENT ❑ DESTRUCTION ❑ A4 Lie-11-5 PUMP INSTALLATION ❑ fnk),6 SYSTEM REPAIR ❑ OTHER ❑ " DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES " DISPOSAL FLD. PROP. LINE FOUNDATION �..�, ,: *:AGRICULTUREWELL.'c"`- s.. -_ <. " 'OTHER WELL � P.ITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Q -r� Dia. of Well Casing 1 Domestic/Private CXGravel P k 'Tracy Type of Casing_ 6_N 170, S r, Specifications �y,�� 510 u I ❑ Public ❑ Other ❑ Delta Depth of Grout Seat f Type crf Grout t ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction".• ❑ Welt Diameter Sealing Material (top 50') " Depth Filler Material [below 501 � TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION LIDESTRUCTION ❑ (No septic system permitted if public sewer is - available within 200 feet.) Installation will serve: Residence Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet:! r Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ IMethod of Disposal Distance to nearest: Well Foundation Property Line 1 LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ; ❑ Distance to nearest: Well Foundation Property Line 1 SEEPAGE PITS ❑ Depth 1 Size Number _ SUMPS-!-- W=M= ❑ Distance to nearest: ,,-'Well-. s - " Foundation--...-_�-.� .:Property-Line" T.�`..,:•r-.� _��._..,�_�-:��"�-«,� 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: "I'certity 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 shalt employ persons subject to workman's compensa- tion laws of California." The applicant must call for all re 'red inspections. Complete drawing on reverse side. a �h ewe ) Signed Title: � L _2Z 5L .T ,.�A r..,r.. . _ Date: Applicafion Accepted by Date ea Pit or Grout.lhspect" �`. ate $ Final Inspection by Date Additional Comments: O Sfk'-s d66-6781"�r's.;-:[j'.,j Vii;," 1 ❑ FAnteca 823-7104 ❑ Tracy A r r r+r -^}"' 9, t S' pplicant FletLmfalkcopies;io:,Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009,SSStk., CAA 95201 a FEE INFO AMOUNT DUE AMOUNT REMITTED K RECEIVED BY r I C DATE PERMIT"NO:' + EH 13.24{REV.l/a5) ]jj EH 14-26 _ .. - 1' S, OC'] �/13� _ ,i