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I k APPLICATION FOR PERMIT • SAN JOAQUIN LOCAL HEALTH DISTRICT i 1601 E. HAZELTON AVE., STOCKTON, CA y Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED w (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, 'Q Job Address H7 (7cc/'I city 06k _ Lot Size PM A Address Y$ir-Owner'sName Phone ��— Contractor's Name ~� License Na A 'a � f]11� h � Phone TYPE OF WELL/PUMP: NEW WELL C. WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION C SYSTEM REPAIR C OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK - SEWER LINES DISPOSAL FLD.__ PROP. LINE `r FOUNDATIONx AGRICULTURE WELL OTHER WELL . PITS/SUMPS INTENDED USE TYPE OF WELL_", PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial C Open Bottom ❑ Manteca Dia. of Well Excavation.. Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack4— - ❑ 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 D T 4'—" — I Type ofDi11Xcr \'H.P. State Work Dane__- Jr Well Destruction ❑ Well Diameter, Sealing Material (top W) Depth lerMaterial (Below 50') .J \ TYPE OF SEPTIC WORK: NEW INSTAL'L"ATION' REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is I/ available within 200 feet.) 'Installation will serve: Residence JL 1 Commercial_t r� Other. Number of Irving units: Number of badmonts C Character of soil to a de,�p/th of 3 feet: 1 �4 f1n(Y�- )- pY11 -. Water table depth C SEPTIC TANK 'hf Type/Mfg %P4-L Capacity la-� tNo.Compartments..- 14L IC - PKG. TREATMENT PLT.❑ y .;^,:, , — Method of-D�isppyml Distance to nearest- Well-L�-2 Foundation�_ Property Line $" j o —/ 1 , , LEACHING LINE_,_.-AC+.No. &Length of lines_ To�31 length/sIze�. i FILTER BED ❑ Distance to nearest: Well:��_ Foundation__C�r1 Property Line i SEEPAGE PITS ❑ Depth /? ,I- Size t ) _ Number t _ SUMPS ) ❑ Distance to nearest: Well Foundation .Property Lihe - 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 District. Home owner or licensed agent's signature certifies the following: '_I.ceitifp that in the performance of the work for which this permit is issued, I shell not t employ any person in such manner as to become subject to workman's compensation laws of California."Contractoes hiring or sub-contracting signature I certifies the following;Z1.cartify.thatin the.performence,of the-work fdrwhich'this permit is issued, I shall employ persons subject to workmen's compensa- tion laws of California." 1 The applicant must call for all req firedj/J��sjp�ections. Complete drawing on reverse side. f Signed X IAS i Title: &11� Iv Date:'�L.. II, FOR DEPARTMENT USE ONLY III Application Accepted bDate l Area Pit or Grout Inspection by -� Date Final Inspection b Dated .T Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6305 • Applicant-.Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 96201 NFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. Ell laz�iaEv.10/631 �5 . pp •�/�rS 85;j7 EN 1L39