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c APPLICATION FOR PERMIT r� 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. Jab Address557?) Cit tot Sizea0 OWAA--, PM Owner's Name Address v� e I Nd- Phone 3 - t1 Contfactt i�(�O S&Address�A PIOX-70 MeyU, License No,a28 Z_14 Phon E O-S(aJ TYPE OF.WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ -DESTRUCTION ❑ ✓ PUMP INSTALLATION ❑ _, SYSTEM REPAIR ❑ OTHER C�'=• 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. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications Fl Public f1 Other CI Delta Depth of Grout Seal Type of Grout I I Irrigation --Approx. Depth I I Eastern Surface Seal Installed by'.. _ Repair Work Done ❑ Type of Pump H.P. F' ".State Work Done_ t _ Well Destruction ❑ Well Diameter Sealing Material (top 50').- - Depth der Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION 1:1 REPAIR ADDITION>d DESTRUCTION INC septic system permitted if public sewer is (��p available within 200 feet.) N Installation will serve: Residence A__11 Commercial— Other 11�� Number of diving units: -./ Number'o edrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK X Type/Mfg , Capacity 1(000 No. Compartments PKG. TREATMENT PLT. ❑ t Method of Disposal F .r Distance to nearest: Well Foundation 0 Property Line IS, ~ z.i k / 01 f LEACHING LINE 17K No. & Length of lines — 0 Total length/size 0 X C7 FILTER BED ❑ Distance to nearest: Well _ Foundation 1 CZ r :-Pfoperty Line 5 SEEPAGE PITS 11 Depth Size Number SUMPS 0 Distance to nearest: Well Foundation Property Line 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 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 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." The:pplicant st call f a l r wired ins ctions. Complete drawing on rever e./ PeSignd X Title: Vt Date: (0 FOR DEPARTMENT USE ONLY Application Accepted by Date � Area Pit or Grout Inspection by Date Final Inspection bv�01—� Date��'� Additional Comments: ❑ Stk 466.6781 ❑ 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 INFO AMOUNT DUE AMOUNT REMITTED I C SH RECEIVED BY DATE PERM17'NO, ♦ EH 13-24(REV,iiN5) o, 3 EH 14.29