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APPLICATION FOR PERMIT SAN .JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES TYEAR FROM DATE ISSUED (Complete in Triplicate) k 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 welUpump and the Rules and Regulations of the San Joaquin Local Health District. Job Address '�- �R•a/�;r / i/ •� /L��4�X�Y�_,� City Lot Size .A � PM Owner's Name C9,4LzLC/iL(!X/Li-a �' AddressPhone 47 a Phone -}ContractoreQ ] / Addre�s� License No �d7 TYPE OF WELL/PUMP: _ NEW WELL'❑' yi,WELL REPLACEMENT O DESTRUCTION ❑-..� PUMP INSTALLATION ❑ ; SYSTEM REPAIR ❑ OTHER El DISTANCE TO NEAREST: -SEPTIC TANK SEWER LINES" DISPOSAL FLD. PROP. LINE s,FOUNDATION"^"""'�'�^�"" A'GR1CFli-T•URE WELL� O.T,HEfl-WELL' PITS/SUMPS INTENDED USE '"TYPE OF WELL PROBLEM AREA CONSTRUCTIC4SPECI�ICA1jIONS ❑ Industrial ^❑ Open Bottom ❑ Manteca x?w Dia..of Well Excavation t. Dia. of Well Casing ❑ Domestic/Private —0-Gravel-Pack' ❑ Tracy -Type of Casing Specifications { f I Public f l Ofher I fl_Delta - _ Depth of Grout Seal Type of Grout i I Irrigation --Approx. Depth I I Eastern Surface Seal Installed by 'Repair Work Done r,❑'-%Type of Pump. H.P. State Work Done_ Well Destruction ❑ Weil Diameter ~Sealing Material (top 501 Depth— 4 y Filler Material (Below 50') -2— TYPE 2 TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence Commercial_ Other Number oftliving units: �`'. Number-of becl ms _ S Character of soil to a depth of 3 feet:`A Water table depth SEPTIC TANK l •4 ' d .Type/Mfg Canacjty ii "' "No. Compartments PKG. TREATMENT PLT :❑ � Method of Disposal X kJ. k Distance"' to nearest' Well Foundation /D Property Line LEACHING LINE 'No. & s Length of.lines.. . Total length/size o? 70 FILTER BED p Distance to nearest: Well 26&4- Foundation Z0 r Property Line S` SEEPAGE PITS t I i Depth Size Number SUMPS ❑ Distance to nearest: WellJFoundation Property Line L7l5POBAC PONDS �" ❑ � • I hereby certify that I have prepared this application and that the work will be dorie 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(tiring 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 applicant must call for II require spections. Complete drawing on reverse ide. p Signed X Title: Date: O. 1/1� _ FOR DEPARTMENT USE ONLY Q�Q Application Accepted by _ Date [t u - .Area Pit or Grout Inspection by rt. Final inspection by Date Additional Comments: ❑ Stk 466-6M,, ❑ 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 96201 FEE INFO AMOUNT DUE y AMOUNT REMITTED CK CASH RECEIVED BY DATE PERMIT-NO. i4 + EH13-24iREV.1/851 ' _7 - - 31 �� EH 14-26 F 1