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//;ate A•�'^, APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED j (Complete in Triplicate) Appliin cation is hereby made to the San Joaquin Local Health District for a permit to construct end/or install the work heroin deseribed.This application is Local Health Distrriicctwith Sen Joaquin County Ordinance No.549 for sewage or No.18Q for well/pump and the Rubs and Regulirtlons of the San Joaquin Job Address /9 City Lot Lot Size -,�'l>'AFE PM Owner's Name < -,t' Address _/!%/J �� J Phone Xr 7- Contractor's Name F'/a?C/C'/S/1 Z` �f eK-_ License No, 7 TYPE OF WELL/PUMP: Phone ,(of NEW WELL G WELL REPLACEMENT G DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ElIndustrial ❑ Open Bottom ❑ Manteca Dis. of Well Excavationr r� Dia. of Well Casing v 1 } j ❑Domestic/Private C Gravel Pack ❑Tracy Type of Casing C Public ❑ Other ❑ Delta TypeofGroSpecifications Depth of Grout Seal Type of Grout ❑ Irrigation —Approx. Depth ❑ Eastern Surface Seal Installed by S I Repair Work Done ❑ T U ype of Pump H.P. State Work Done_ O_ Well Destruction O Well Diarneter Sealing Material(top 50') { Depth Filler Material(Below 50') I TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ DESTRUCTION C (No septic system permitted if public sewer is 1 available within 200 feet.) ` Installation will serve: Residence /� Commercial__ Other I 1 Number of living units: Number of bedrooms _ Character of soil to a depth of 3 feet: l t_^I y Water table depth � / SEPTIC TANK Type/Mf { t g f'1��--�1 {y CapacitY /1 Ln0 No. Compartments k PKG.TREATMENT PLT.❑ Method of Disposal Y '� vt /r_ { Distance to nearest: Well /60 Foundation <-' Property Line "— 4, LEACHING LINE No. & Length of lines %� —�y� _ Total length/size f�� X 2 FILTER BED ❑ Distance to nearest Well C FFoundaticn /C �_ Property Line 1 SEEPAGE PITS 11-'i- Depth Z,S— Size Number_ L SUMPS Distance to nearest: Wellr .00L� �Foundation fP0 Property Line DISPOSAL PONDS C I hereby certify that I have ( Y fY prepared this application and that the work will be done in accordance with San Joaquin county ordinances,stere laws,end 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 iswed, I shall not employ any person in such manner as to becomo subject to workman's compensation laws of California."Contractor's hiring or subcontracting Signature certifies the following:"I certify that in the performance of the work for which this pormit is issued,I shalt employ persons subject to workman's compenSa- tion laws of California." The epplica us alt for all required ins t, plate drawing on reverse side X_�� -�' Signed Title: .']ate: FO DEPARTMENT USE ONLY l . ._��Application Accepted by I Date Ars_ Pit or Grout Inspection by / et -/ -yy - _ - �, Final Inspection by Additional Comments: ❑ Stk 466-6781 Ci Lodi 369-3621 ❑ Mnnteca 8237104 ❑ Tracy 835-6366 Applicant-Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 96201 FETED x E AMOUNT DUE AMOUNT REMITSH S RECE FO CAIVED BY DATE PERMIT No. N . EH 13-24(REV.10183) EH 14-20 7 y-S7 g