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APPLICATION FOR PERMIT 4 SAN JOAO.UIN.LOCAL HEALTH DISTRICT �f 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 9 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. 549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. City 57-Ie t.) Lot Size PM Job Address �. r°,4L ,lr1�Sr p�0a<'LS Address �� E Phone Owner's Name ILicense No. i��SPhone Contractor �02 Woap � Address TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION 0 OTHER O -�-. - -T�=RUMP INSTALLATION.❑ SYSTEM REF!,W_. l____ _,_. _ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE I 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. of Well Casing EJ Domestic/Private 17 Gravel Pack L1 Tracy Type of Casing + Specifications M Public Ll Other Cl Delta Depth of Grout Seal Type of Grout — I I Irrigation --Approx. Depth I 1 Eastern Surface Seal Installed,by 3 Repair Work Done ❑ Type of Pump H.P. State Work Done #} t Well Destruction ❑ Well Diameter Sealing Material flop 50'1 A t Depth Filler Material (Below 50'4 I c�i11 - I TYPE OF SEPTIC WORK: NEW INSTALLATION I REPAIRIADDITION l I DESTRUCTION l I (No septic system permitted if public sewer,is # available within 200 feet.) 1 I Installation will serve: Residence Commercial— Other E I ► Number of living units: _>t..— Number of bedrooms Character of soil to a depth f 3 feet: t / I Water table depth p ltr� y. No. Co artments �` v SEPTIC TANK Type/Mfg _ ;pr� Capacity -.. P I r ) A of Disposal PKG. TREATMENT PLT. ❑ Method l s.. 9, -•r-'-` � � r1 Distance to nearest: Wel ,Foundation -- Property.Line lZ*7 \\ LEACHING LINE No. & Length of lines 2—` �� ` dotal length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line � 7 SEEPAGE PITS I Depth __Size 4Number` SUMPS is Ll Distance to nearest: Well S4 f=oundation /Al ' Property Line DISPOSAL PONDS ❑ k I hereby certify tliat-1:1 ave prepared this application and thai the work will be done in accordance with San Joaquin county ordinances, state laws, and k rules an8 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 issued, f shall not employ any person in such manner as to become 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 permit is issued,I shall employ persons subject to workman's compensa- tion Iaws of California." The applicant must call for all requi;n, inspection Complete drawing on reverse side. I ZZt�P y� Signed X - ._ - - _ Title: _ ---Date. FOR DEPARTMENT USE ONLY r VX Application Accepted by ]J _�" H Date 2 Area / Pit or Grout Inspection by ata Final Inspection by Date �1 Additional Comments: g ❑ Stk 466-6781 a 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 CASK RECEIVED BY DATE PERMIT'NO. INFO �f r EH 13.24(REV.I H 5) �YJ a EH 14-2a