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APPLICATION FOR PERMIT ' SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES TYEAR 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 I City Lot Size bl, ALxt PM Owner's Name . Address Phone Contractor Address cense No42 'r`d9 Phone TYPE OF WELL/PUMP: EW WELL?C WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION, SYSTEM REPAIR ❑ OTHER ❑ pA DISTANCE TO NEAREST: SEPTIC TANK ".�. SEWER LINES DISPOSAL_ DISPOSAL FLD. PROP. LINE FOUNDATION S'�1` - AGRICULTURE WELL OTHER WELL_%4&_e PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation " Dia. of Well Casing re F �[Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing L Specifications / F] Public F1 Other F1Delta Depth of Grout Seal Type of Grout I I Irrigation --Approx. Depth I I Eastern Surface Seal Installed by - Repair Work Done ❑ Type of Pump 11 H.P. V2- ` '` State Work Done Well Destruction ❑ Well Diameter Sealing.Material [top 501 - peptti —Filler Material IBelow 5('i� TYPE OF SEPTIC WORK: NEW INSTALLATION l I REPAIRIADDITION 1 I DESTRUCTION I I INo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence= Commercial_ Other Z . Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: -w- 'Water table depth SEPTIC TANK ❑ ,Type/Mfg Capacity `� "" No. Compartments t I PKG. TREATMENT PLT. ❑ - Method of Disposal ; Distance to nearest: Well_� Foundation k' 1 Property Line i i f LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well -� Foundation Property Line SEEPAGE PITS ( I Depth Size Number 1110 SUMPS FI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 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 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 taws 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 mus all or require ions. Complete drawing on reverse side. �i Signed X Title: )(22k�Y.a . Date: A6 Ae�;rle7 t FOR.DEPARTMENT..USE ONLY-- Application NLY Application Accepted by �, Date Area d _ Pit or Grout Inspection by Datery p„56� Final Inspection byDate I! v� Additional Comments: r b ✓ � ~ ❑ Stk 466-6781 LJ Lodi -3621 ❑ Manteca 823-7104 C1 Tracy 835-6385 re„� 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 RECEIVED BY DATE PERMIT'NO. INFO C .'2H 13-24 IREV.t i x 5, EH 14-28 i��t (dam /Z�� 9- 3 'O