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i. APPLICATION FOR PERMIT 1 SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 7 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.579 for sewage or No. 1962 for well/pump and the Rules and Regulations of the San Joaquin ' Local Health District. r� 3a A d� Job Address L, LAC � a� (�" CityLot SizeKLAAP M - Owner's Nam L Address I ft"' "�`� Phone — -_ Contracto dL 1. _Address, license No.328Z-_21, Phone , TYPE OF WELL/PUMP: " "NEW WELL L - WELL REPLACE NT ❑ DESTRUCTION ClPUMP INSTALLATION LlSYST REPAIR U OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LIN _ DISPOSAL FLD. PROP. LINE FOUNDATION AGRI RE WELL .._ OTHER WELL PITS/SUMPS i INTENDED USE TYPE OF WELL PROB AREA CONSTRUCTION SPECIFICATIONS J Industrial ❑ Open Bottom anteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack L7 Tracy Type of Casing - Specifications fl Public - ❑ Other rn Delta Depth of Grout Seal _. Type of Grout__ _ 1 1 Irrgavon prox. Depth I I Eastern Surface Seal Installed by Repair Work Done O ype of Pump _ H.P. State Work Done _ Well Destruction Well Diameter Seating Material ftop 50'1 Depth Filler Material IBalow 509 - TYPE OF SEPTIC WORK: NEW INSTALLATION I I RI PAIR/ADDITION I I DESTRUCTION 1 I (No septic system permitted if pubic sewer is 6 available within 200 feet.) Installation will serve: Residence x Commercial_ Other Number of living units: _1_ Number of sdrooms__ E Character of soil to a depth of 3 fait: _ .s'-x---�t� _ Water table depth SEPTIC TANK ❑ Type/Mfg _ Capacity __ No. Compartments PKG- TREATMENT PLT.❑ Method of Disposal Distance to nearest: Weil _- Foundation Property Line LEACHING LINE 41 No. 8 Length of lines? / Toth length/size _ -/ FILTER BED ❑ Distance to nearest; Well Foundation f / Property Line SEEPAGE PITS I I Depth 100 Size'-� X Number _ SUMPS li Distance to nearest: Well• Foundationtd r Property One DISPOSAL PONDS ❑ 1 hereby cenity 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 Josquin 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 shah not employ any person in such manner as to become subject to workman's compensation laws of California.-Contractors hiring or subcontracting signature certifies the following:"I certity that in the performance of the work for which this permit is issued,I shah employ persons subject to workman's compena- tion laws of California." The applicant muuasTt/?II for all required i nspe ction. Complete drawing on reverse side. Signed Title- Date: FOR DEP A//RJJ ENT USE ONLY A licetion Accepted by�, Old_ Date ✓ ��i� Area or roti n, ction by Data Final Inspection by rr�-i� Date, Additional Comm, " L Stk 466-6781 ❑ Lodi 369-3621 L Manteca B23-7104 ❑ Tracy 83563851 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 CASH RECEIVED 11Y DATE PERMIT NO. INFO ..EH 1..ar IREV.hrxS� /S' E/1 167e O