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APPLICATION FOR PERMIT SAN JOAQUIN LOCACHEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete k.'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 Ryles and Regulations of the San Joaquin Local Health District. A�JotiAddress,^7(L,� Ci Lot Size pfyl ti r 41 Owners Name 4 Address 900 Phone a Contract Address 0, 80-k -14277 �-�� License No.��Phone TYPE OF WELL/PUMP: NEW WELL D WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ r 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 1 ❑ Industrial ❑ Open Bottom ❑ Manteca Dia.of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing 4 Specifications ❑ Public ❑ Other ❑ Delta Depth-of Grout Seal _� Type of Grout ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done 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 Number of living units: Number f bedrooms Character of soil to a depth of 3 feet: �+f Water table depth Q r SEPTIC TANK ❑ Type/Mfg Capacity . .No.'Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation i - Property Line 1 / � 1 LEACHING LINE P"No. & Length of lines -_[ qQ j `Total length/size 'I[J0 X FILTER BED ❑ :t Distance o nearest1Nell f _ ��_ Foundation �� Property Line SEEPAGE PITS 1❑ Depth Size c- X t0 !' Number , SUMPS 93' Distance to nearest: Well 5JO Foundation: f D r 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. " / 1 Home owner or licensed agent's signature'certilfies 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-tubject to workman's compensation laws of California."Contractors hiring 6f sub-contracting signature certifies the following:"I certify that in the performance of the work forwhich,this p6rmit is issued,l-shall employ persons subject to workman's compensa- tion laws of California." The applicant must call fo^ll required inspections. Complete drawing on-,reverse side.v Signed ' Title: , F t V � Date: FOR DEPARTMENT USE ONLY Alication Accepted by7 Date ._ _ __ Area o GroufTnspection by Date--='1 Final Inspection-by Date� Z ` --•�Additional-Comments:' -�*_- , --•- --- • -• -�----� - - __ .._ / /�,/ _ _ __...�.-__,. _ O Stk 466-6781 D Lodi 3693621 D Manteca 823-7104 e❑ Tracy 835-6385I 1 , Applicant- Return all copies to: Environmental Health Permit/Services 1601 E.Hazelton Ave., P.O..'Box-2009, Stk., CA 95201 z . ._.... .___ --.rte -:•--•.— -_...�. � yet. ...�._.. _. _ ., '�,: .... ._ _._ .-, -_, PEE AMOUNT DUE AMOUNT REMITTED CIC#INFO CASH RECEIVED BY DATE PERMIT`140. +EH 13-24 1REV.1/B 5) EH 14-26 i