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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 Wealth Distric ,L Q -r--O Job Address City M 4 k rE C Al-ot Size 3O rler'�PM r,.s t _ p 3 Owner's Name ress zaf Z'8��r-�-�� IL)9 4!dY 1�Q _ Phone a Contractor Address License No. Phone_ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP, LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS Il 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 ❑ Tracy Type of Casing Specifications n Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout _ I I Irrigation _Approx. Depth I I Eastern Surface Seal Installed by _ Repair Work Done D Type of Pump H.P. State Work Done Well Destruction 0 Well Diameter Sealing Material (top 501 Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION IK DESTRUCTION l I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: ResidenceCommercial_ Other Number o1 living units: —]— Number of bedrooms 2- l Character of soil to a depth of 3 feet: S A-n Q Y " Or-ol Water table depth SEPTIC TANK P Type/Mfg `"L &4C-rr-t — Capacity 1 �1 UO No. Compartments PKG. TREATMENT PLT. ❑ r I Method of Disposal LerRGtq e:...iY1 " Distance to nearest: Well 2-00 Foundation t Property Line LEACHING LINE 91,�No. & Length of lines J� -_3" 7 Ooi Total length/size I .Ve X Z_ O ! FILTER BED ElDistance to nearest: Well Z 400' Foundation d Property Line SEEPAGE PITS { I Depth Size _ Number SUMPS U Distance to nearest: Well Foundation Property Line 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 laws, and rules and regulations of the San Joaquin Local Health Di§trict. Home owner or licensed agent's signature certifies the following: "1 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." 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 m t ca for uir ins tions. Complete drawing on rev rse side. X�y Signed X Title: ,. Date: F DEPARTMENT USE ONLY Application Accepted by Dates��j�� Area 1`� 07Z Pit or Grout Inspection by Date Final Inspection by Date Additional Comments:/ ❑ Stk 466-6761 ��/ ❑ Lodi 369-3621 ❑ Manteca 623-7104 ❑ Tracy 835-6385 Applicant - Return 11 copies to: Environmental health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED K //RECEIVED BY DATE PERMIT'NO. +.fH 13-24(REV.F/HSI * �b ( }� '117tsq � -9EH 14-26 11}-. I