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I APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T 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 4L. f,t, Lotj,` t- City Lot Size 3 PM c ri t A(,-CA y Ln�dG S`A Owner's Name _-_ Address tv,��, Phone �++ Contractor tI o S Address'Q License fQ012? S Phon y' TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ i PUMP INSTALLATION SYSTEM REPAIR El DISTANCE TO NEAREST: SEPTIC TANK //D "r OTHER ❑ , I -_ SEWER LINES DISPOSAL FLD./5c? PROP. LINE /DO FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIO S ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of_Well Excavation L Dia. of Well Casing _ `Domestic/Private V Gravel Pack ❑ Tracy Type of Casing F' z/ Specifications i i 7 Public n Other ❑ Delta Depth of Grout Seal I00 E�I Irrigation Type of Grout c�,�--_ J -%-40--Approx. Depth I I Eastern Surface Seal Installed bySS6v_7A&1_ rZ Repair Work Done _ ❑ Type of Pump - H.P. 2, State Work DoneiV�/Z Well Destruction 11Well Diameter Sealing Material Itop 501I Depth Filler Material (Below 50'1 TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ DDITION i 1 D TRUCTION I I (No septic system permitted if public sewer is r available within 200 feet.) Installation will serve: Residence— Commercial— Othe 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 Distance to nearest: Well oundation Property Line LEACHING LINE ❑ No. 8r Length of lines Total length/size 4laws, 1 FILTER BED ❑ Distance to nearest: We Fou dation y Property Eine SEEPAGE PITS I I Depth Size Number SUMPS ❑ Distance to nearest: Well Foundati n Property Line DISPOSAL PONDS I.7I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances,rules and regulations of the San Joaquin Local Health Dlistrict. Home owner or licensed agent's signature certifies the followinam to an g: •"i certify that in the performance of the work for which this permit is is , employ y person in such manner as to become subject to workman's comperisation 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." The applicant must call for allsquired inspections. Complete drawing on reverse side. Signed X Tide: _ _ Date: FO"DEPARTMENT USE ONLY Application Accepted by Date Area Pit or rou Inspection byAA� ateFinal Inspection by J Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 635-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK INFO RECEIVED BY GATE ".f _ / SH PERMIT'NO. i +.EH13-24(REV.ve51 /0�' _ __p. EH 14-26 ! 0J__