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f r APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON ON AVE., STOCKTON, CA Telephone (209)466-67$1 PERMIT EXPIRES 1 YEAR'FROM DATE ISSUED (Complete in Triplicate) ' ~ F t ? y.�Iy.'�, Application is hereby made to the San Joa:.quin Local Health District for a permit to construct and/or install the work herein described. This application is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Ryles and Regulations of the San Joaquin Local Health District. , ' ,, {� Job Address _�_ r r' y�'4•W�6 ' �� a. Cit�,V r of Size PM Owner's Name Address p` - Phone 1 ��$nh A.I Address a?1�7 D 1 r( C1 O X License No. r t phone 3/', TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION X 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 ; ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation _ Dia) Well Casing Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications Q Public ❑ Other ❑ Delta Depth of Grout Seali EJ _ Irrigation A Type of Grouti, --Approx. Dept ❑ Eastern Surface Seal Installed by 1 i Repair Work Done ❑ Type of Pump 0,6 H.P._ I State Work Done 41 -- r 11 ft Well Destruction ❑ Well Diameter Sealing Material ;top 501 - ; Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if-public sewer is available within 200 feet.) Installation will serve: Residence— Commercial— Other i 5 I LU I umberof living-units;-�-----�NulYlber f lietlr�rt5� - rA Character of soil to a depth of 3 feet: .t' i�A ti,_" f'1 Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments s�` h PKG. TREATMENT PL-T:(^� - 1 In 1 "" M171�hotl of-Disposal VI D.istarice'j,to nearest: Zwell Foundation Property Line 11--- LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest all Foundation Property Line .l.v5if i M SEEPAGE�PIT-S—"----a-•-Depth— - ,.._ Size t---- -_— �_ Numbel'......".."' SUMPS ❑ Distance_ to nearest: Well FoundationProperty Line (� DISPOSAL PONDS ❑ `�.��r� I here y certify that I have prepay -this application and-tha"'�t""the work will-be done m actor ancewitTFSan Joaquincounty ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. f 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." Contractor's hiring or sub4jcontracting 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 must call for all required inspections. Complete drawing on reverse side. z Signed 71` _ Title: r Date: F DEPARTMENT USE ONLY fi Application Accepted by Date -fArea Pit or Grout Inspection by Date s^ 77 Final Inspection by Date Additional Comments: 1 I C1 Stk 466-6781 Q Lodi 369-3621 Manteca 823-7104 ❑ Tracy 835-6385 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 INFO CASH RECEIVED BY DATE, PERMIT`NO. + EH 1324(REV,i EH 14-26 �/�� C _Q