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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL 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 05 Q City Lot Size PM Owner's NamewAL1`� .0 o-) _ Address �JQ� �✓- QJ�C D_k Phone �� 1 Contract 4 r r AddressO.0. 9tr1 r License No.��Z4 Phone �ai 5f a TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES �. DISPOSAL FLD. PROb. LINE ,4 FOUNDATION AGRICULTURE WELL OTHER WELL I PITS/SUMPS _1 } INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack 0 Tracy Type of Casing Specifications (`l Public � M-Other - - �- - - 71 Delta Depth of Grout;Seal. - Type of Grout _ 'X 1 I I Irrigation ''_.Approx. Depth I I Eastern Surface Seal Installed,by _ V Repair Work Done ❑ Type of Pump x H.P. tT^ State Work Done _ w- Well Destruction ❑O Weil`Diameter ` Sealing Material (top 50'1 f -- Depth - + Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITI0N;I'1` DESTRUCTION I I (No septic system permitted if public sewer is t- Tom__ . - . . _.. available within 200 feet.) Installation will serve: Residence Commercial_ ther Number of living units: Number 9f drooms Character of soil tots depth of 3 feet: ��! Water table depth SEPTIC TANKl"` Type/Mfg r -f-tapacity-X010 No. Compartments PKG. TREATMENT PLT. ❑ - ! ! Method of Dispcysal Distance to nearest: I Well Foundaiion w Property Line` 0211T LEACHING LINE 3 No.A Length of lines — Total length/size Q. FILTER BED ❑ Distance to nearest: Well 1130 Foundation Property Line f If ' SEEPAGE PITS TI. Depth Sizes Number r SUMPS Distance to nearest: Well1.Q _. • Fouridation A 0 Property Line } DISPOSAL PONDS Cl 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. 4 Homeowner 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 t call for a quir d'inspectinns:Complete draWido on reverse sr � Signed X Title: 1/' � — Date-,00 FQR DE ARTMENT USE ONLY Ap�!',onAc.r...piod by Date o -7AreaPitction by Date q Final Inspection by� Date �� Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6365 ` Applicant - Return ail copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 I FEE INFO AMOUNT DUE AMOUNT REMITTED CASH CK RECEIVED BY DATE t PERMIT'NO. +.EH 13-241REV.rixsf EH 14-28 �(�O d