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I ' APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL I ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED i (Complete in Triplicate) M 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 cf the San Joaquin Local Health District. I. p Job Address Jt�1 l� ��2k '`� 2322 J'!C, t"2 Lot Size PM �^ E J`�r G�� lLAddress }r 1� Owner's Name 1�f Q 1 � Addressf1l� �1 Phone i Contractor 1 Address fie- License No. Phoned orb-D f TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT El DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE I FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS s d 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 ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done El Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATIO REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) I Installation will serve: Residence_ Commercial kl_ Other j 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 _1 PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE No. & Length of lines gt �' Total len hlsiz FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 4K Depth a Size 3.3 Number t-� SUMPS 0 Distance to nearest: Well /fir"-fes Foundation 'sem Property Line / DISPOSAL PONDS ❑ 9 t /4 s' LF �t I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin coun ordinances, state laws, and 1 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 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 call for II equ' d inspections. Complete drawing on reverse side. Signed Title: I Date: , j FOR DEPARTMENT USE ONLY Application Acceptedby f l Date —3 —2 Area T Pk or Grout Inspection by Date16- Final Inspection by �l ' Date�_�c ri Additional Comments: < S a it e- ) — 2a A V-c 1 U e n r o u r { ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6M- Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.Q. Box 2009, Stk., CA 95201 r FEE INFO AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT"N0. t � l* EH 13-24(REV.1/857 `'L • C?C� l �) '` T �! i?tiL7•`la i EH 1446