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'F Nom...- .'.. -:' ,:.....- ..'.-' -: .'. ............ ... n. ..n._ APPLICATI®N FOR PR SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE.T ON AVE.. STOCKTON, CA [ Telephone (209) 466-6781 { PERMIT EXPIRES 1 YEAR FROM DATE ISSUED,.,_, (Complete in Triplicate) - r 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 7 ;2 /! SrxesBr city rYA CO Lot Size .�`/'�GYC'f Ply Owner's Name A4 Address AN {'?/4 Y �� Phone Contactor s Name A License No. ��Y+_ Phone I TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ SYSTEM REPAIR ❑ OTHER Cl PUMP INSTtLLATION 11 DISTANCE TO NEAREST:_SEPT.ICTANK--�-'�--_ ,,, SEWER LINES DISPOSAL FLD. POOP. LINE { z FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ 14__ INtENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS I ❑ lndustrial ❑ Open Bottom Manteca Dia. of Well Excavation Dia. of Well Casing F J M Domestic/Private b Gravel Pack C3 Tracy Type of Casing Specifications 1 R j ❑ Public ❑ Other C1 Delta Depth of Grout Seal Type of Grout {)) ❑ Irrigation �__Approx. Depth 11 Eastern Surface Seal Installed by I Repair.Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ �ell Diameter Sealing Material {top 50'} t Qepth ? Filler Material (Below 501 f TYPE OF SEPTIC WORK: I NEW INSTALLATION ❑,4"REPAIR/ADDITION Cl DESTRUCTION ❑ (No septic system permitted if public sewer is j available within 200 feet.) /.. Instolation,will serve: Residence Z Commercial y ther NurAve'of livmg urnts:_-_#'YJ_ Number of bedrooms Character of soil to a depth of 3 feet: t Water table depth � f SEPTIC TANK Type/Mfg 15'0 €AST Capacity 071500^ No. Compartments PKG. TREATMENT PLT. Method of Disposal Distance to nearest: Well Foundation l4• Property Line .91 LEACHING LINE ❑i o. & Length of Iles. Total length/size FILTER BED 1 Distemm-to-fmYe r-'S Well. ' Foundation -IL4-o Property Line SEEPAGE PITS ,'❑ Depth Size Number SUMPS ❑ Distance to nearest: ➢ Well Foundation Property Line t; `a- ..a' . DISP05AL PONDS/ ❑ �"`"�, � �� 4T,t I hereby certify that k have prepare°d t 5is apptic io'n and that the work will be done in accordance with San Joaquin county.ordinanries%tate laws, and rules and regulfitions of the San Joaquin LorfafJra'dlth District. _ - Hojne;owner or licensed agent's signature oerti ie t1�e following:"I certify that in the_perforrce of the work for which this permit is issued, I shall not ern6loy any person in such manner as to become subject to workman's-comFsensation laws of California."Contractor's hiring or sub-contracting signature i certijJ64 the following:"I certify that in the p 4fo0a rr¢e:-of the work for which this permit is issued,1 shall employ persons subject to workman's compensa- tionlwS of California." = The applicant mu -call,for all required inspections. Complete drawing on reverse side. f Signed X og;&& Tide: Date- av 1 FO�1 EPARTMENT USE ONLY r Application Accepted by + / �7� Date Area ! 7f0 Pit or!.Grout Inspection by •-Da#e- 1 Final inspection by �� Date t Additional Comments: ❑ Stk 466-6781 11 Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835345 Applicant- Return all copies t : Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O.Box 2009, Stk., CA.95201 FEE INFO AMO(JNT DUE AMOUNTtREMITTED CASH RECEIVED BY DATE PER{VS1T`N0. +EH 13-24[REV.10/631 !/vve ILA Eli 1426