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APPLICATION FOR PERMIT 13 , SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR•FROM DATE ISSUED yj (Complete in Triplicate) i 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. 1662 for weupump and the Rules and Regulations of the San Joaquin Local Health District.Lie _ f Job Address — � � �� el City f�a' Lot Size PM Owner's Name _ Address\1 i?31 �1 a °z Phci,�,34 ��I Coniractrsr I Addresl; i'a0 t' �0 i�c License No. zS z26 Phone d I TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ j PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE.TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE , FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE T TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia.of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other F-1 Delta Depth of Grout Seal Type of Grout I i I I Irrigation ..--Approx. Depth I I Eastern Surface Seal Installed by - F Repair Work Done ❑ Type:of Pump H.P. State Work Done Weil Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50'I� f t TYPE OF SEPTIC.WORK: NEW INSTALLATION.Irl.^F3E-PAIR/A[5DIT.ION I I ,DESTRUCTION 1,I'ANo septic system"permitted if public sewer is ` / ,avaiilla'ble_within_200 feet.( 11'nstallation-wi]I;serve:, Residence Commercial--.-Other "° - 1 Number of living units: r '' Numbe_'of bedrooms Character of soil to a depth of 3 feet: Wa"ter-.table depth SEPTIC TANK Type/Mfg Capacity fln e?7 �= --No7Compartments PKG. TREATMENT PLT. ❑ n /r Method of'Disposal Distance to nearest: Well _��-Foun/dation �f Proparty.Line �2 LEACHING LINE No. & Length of lines Total length size FILTER BED Distance to nearest: Well Foundation Property Line SEEPAGE PITS I'l Depth Size �� Number SUMPS l Distance to nearest: Well 4 Foundation Property Line 7-.:2 DISPOSAL PONDS ❑ I hereby certify that I have prepared.this application and that the work will-.he done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health Diltrict. Horne 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 shalt 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: "t certify that in the performance of-the work-for-which.this•permit is issued,-shall employ persons'subject to workman's compensa- tion laws of California." lI The applicant must coil for all required i ions. Complete drawing on reverse side. + Signed X Title: Date: X h FOR DEPA TMENT USE ONLY Application.Accepted.by. - - - -- —;Date r !!-7——Area-— - ----- - or out Inspection by at Final Inspection by Date Ad itiona o ants: _ I] Stk..466-6781 ❑ Lodi 369-3621 Ll 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 II -. " EEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. INFO CASH i +. SH 13-24(REV.+i x 55 EH 14-26 h