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I + APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA + Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED r . (Complete in Triplicate) Application is hereby mede to the San Joaquin Local Health District for a permit to construct and/or install the work he in 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 an Regulations of the San Joaquin Local Health District. 1 Job Address I �t7C �_�I� tr!< City _ Lot Size PM 4 r V � t .c,/+1 !moiS Phone F•.3 -Ark Owner's Name �'r�� Address QLD i Contractor_. �12 Ao Address ��r �� T� License No.41L Phone TYPE OF WELL/PUMP: NEW WELL G WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ ` DISPOSAL FLD- ROP. LINE DISTANCE TO NEAREST:'SEPTIC TANK SEINER LINES FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PR06LEM AREA CONSTRUCTION SPECIFICATIONS p Industrial ❑ bpen eotidm ❑ Manteca -Dia:'of"Well Excan6atio4" -D '•of-Well-Casing'' ❑ Domestic/Private =1 Gravel Pack ❑•Tracy Type of Casing Sl iecifications [ r PuWic T e of Grout Other i 7 Delta Depth of Grout Seal p I Irrigation —.Approx. Depth I Eastarn Surface Seal Installed by t H,p,/ - Repair Work Done i❑ Type of PumpState Work Done r i Well Destruction ❑ Well Diameter Sealing Material stop 50'f , I Depth Filler Material (Below 50') 1 ; TYPE OF SEPTIC WORK: NEW INSTALLATION :l REPAIR/ADDITION DESTRUCTION I I (No septic systerr permitted if public`sewer is _ available within 210 feet.) ,{ Installation will serye: Residence Commercial''' Other Number of living units: _L_ Number of bedrooms _ ttti Character of soil lata depth of 3 feet:,{ �� L-.__� Water tab) depth Y t SEPTIC TANK' ❑ Type/Mfg K'` r. Capacity��-- No. Compo mems F P.KG- TREATMENT PLT:❑ { "^` f Method of isposal f - Distance,to nearest: Well Foundation Property Line LEACHING _ i •- '9 �- �Q r V" Total length/size..-- T LEACHING LINE of hues r - L ___� r FILTER BED �� Distance to nearest: Well�h��-. Foundation/d Property Liner f 4� SEEPAGE PITS l 11 Depth '7i, ' .` Size +• y Number `SUMPS`' 'ff Ci 'Distance to rieaiest: Well_ __' ___Foundation Property Line DISPOSAL PONDS 0 Y 4 lihereby certify that I have prepared this application anZthat the,work will be done in accordance with San Joaquin aunty ordinances,state laws, and rules and regulations of the San Joaquin.Local Health District. ._. !' HomB,//bwner or'licensed-agent's signature certifies the following: "I certify that in the performance of the work for ch this permit is issued, I shall not eYnpl6y any person;in such mbnner as to become subject to workman's compensation laws of California."Contractor' hiring or sub contracting signature certifies the following:"I certify that in the performance of the work for which this permit is issued,l shall employ perso 's subject to workman's compensa- I Von laws of California." ` vY The applicant must.call for required inspections. Complete drawing on reverse side. c 'Date- FOR ate- Signed X �r_ 'w'�-'r-} 'Title: 4f FOR DEPARTMENT USE ONLY . 7 Application Accepted by g� Date Area Q� i�r IDate_. Final Inspection by Date�� Pit or Grout Inspection by Additional Comments: r i1 Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Retum all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave„ P.O. Box 2009, Stk., CA 95201 FEEAMOUNT DUE.. -. . AMOUNT EMIT7ED :CASH --RECEIVED i3Y —DATE'— "PERMIT NO.` .. tNFO .'EH 13-24 tREV.I n�, EH 14-24 ro