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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1-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. f _ r Job Address T City S' 11:fA✓ Lot Size PM Owner's Name 4,41ZR Address 114' 4.eD S77-4.rJ Phone y'3 3/3 Contractor rZ-QVQ L W6701> Address A� AD-C E -f License No'. S121177-76 Phone J!L4_-S'-3` -71 TYPE OF WELL/PUMP: NEW WELL El ---WELL i -REPLACEMENT ❑, DESTRUCTION ❑1r 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 ❑ Industrial D Open-Bottom ` ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack -� .❑ Tracy Type of Casing Specifications f'l Public _ xry r ❑ Other f l Delta Depth of Grout Seal Type of Grout I I Irrigation _..Approx. Depth I I Eastern Surface Seal Installed by r Repair Work Done D Type of Pum p YP p =,< H.P. State Work Done I Well Destruction ❑ Well Diameter �+'Sealing Material {top 50') Depth', Filler Material (Below 50') TYPE OF SEPTIC WORK: " NEW INSTALLATION REPAIR/ADDITION I ) DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) +f Installation will serve:, Residence--� Commercial— Other— Nu Number of living units: P r` Number of bedrooms Character of soil to a depth of 3 feet: A.Q y Water table depth SEPTIC TANK ❑ Type/Mfg 19Capacity //4�JD No. Compartments PKG. TREATMENT PLT. L1 . ''f., -'_1 1\-, % Method of Disposal Distance to nearest_' Well J��- Foundation_ /td's Property Line 4_0 r LEACHING LINE LN' No. & Length of lines' �} - Total length/size W FILTER BED CI Distance to nearest: Well /eO7A_ .Foundation 7ejO Property Line f SEEPAGE PITS t"l Depth 7, � p Size Number { SUMPS CI Distance to nearest: Well j_'Cd >` Foundation "7�z Property Line 41 DISPOSAL PONDS ❑ I hereby certify that I have preporad this—application sapp )(cation 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. - A 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, 1 shall not employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting 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." l The applicant must call for all required inspections. Complete drawing on reverse side. I Signed X-4 � _ Title: Date: R DEPARTMENT USE ONLY Application Accepted by Date Area 1 11 Pit or Grout Inspection by Date Final Inspection by5 Date L ` i Additional Comments: i } ❑ Stk 466-6781 CJ Lodi 369-3621 ❑ Manteca a23-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk_, CA 95201 ~ I INEE OUNT DUE AMOUNT REMITTED H RECEIVED BY DATE PERMITNO. I +.EH 13-24(REV.tiHs) -b-Z) � ��EH 14-28 b V �.J Fra -- C