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f A APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES TYEAR FROM DATE ISSUED I (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. a, ��- Job Address !Q! � f��°1.iA City .��d/� Lot Size �?axA� PM Owner's Name A4& � Address S/¢m� Phone r -7-73- A, Contractords� ir7 JnV Address Ay 7 License No. Phone TYPE OF WELL/PUMP: NEW WELL;❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR El OTHER ❑ j DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE s FOUNDATION AGRICULTURE WELL OTHER WELL'y t ' - PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing I] Domestic Private .0,G1 vel Pack, ❑ Tracy t Type of Casing n Specifications fl Public .F" ❑ Other n Delta Depth of Grout Seal Type of Grout _ I I Irrigation —.-Approx. Depth I Eastern t" "" Surface Seal Installed b'y- �f Repair Work Done ❑ Type of Pump TH.P. State Work Done i. Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth t'Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I i REPAIR/ADDITION DESTRUCTION l 1 (No-septic system permitted if public sewer is at" available within 200 feet./ � re Installation will serve: Residence X Commercial_ Other 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. ❑ i Method of Disposal Distance 10 nearest: Well Foundation Property line LEACHING LINE No.'& Length of lines �� 6 Total length/size 4 FILTER BED fl Distance to nearest: Well c7D Foundation Property Line ` I SEEPAGE PITS X1 Depth ;.z50' —_Size 33 � ,Number 1 SUMPS ❑ Distance to nearest: Well Foundation t Property Line ,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 lJandr rules and fegulations of the San Joaquin Local Health District. 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 td workman's compensa- tion ompensa tion laws of California." _ The applicant must call for all required inspections. Complete drawing on reverse side /�// Signed X J✓Lzrr ��.�""`�'-- Title: Date:' -C-947 O �PARTMENT_USE ONLY,4 Application Accepted by ` Date Area Pit r Grout Inspection byf ate inal Inspection by Data 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 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT•NO. INFO CASH t.EH 13-241REV.I/K5) C:> EH 14-28 ' .