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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZETON 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. q Job Address 1 I — `2Za.—ALK2/A-r L 4V City Lot Size Ir o 4- q, PM Owner's Name h U CL— c 1 I le M 1,A) Address J 1_.�7.�- / . 4sa/a)c Phone Contractor I' K el ddress License No. 32SW(l Phone 347 -7.,� TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION C' SYSTEM REPAIR -1 OTHER ❑ I DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL F D_ PROP. LINE FOUNDATION AGRICULTURE WELLWELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONST ION SPECIFICATIONS L_I Industrial ] Open Bottom I1 Manteca id. of Well Excavation__ _ Dia. of Well Casing U Domestic/Private ❑ Gravel Pack I I Tracy Type of Casing Specifications Public C Other Del Depth of Grout Seal Type of Grout Irrigation _Approx. Depth as Surface Seal Installed by Repair Work Done L Type of Pump _ H.P. State Work Done Well Destruction i Well Diame Sealing Material (top 50') Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION PAIR/ADDITION IFT DESTRUCTION U Wo septic system permitted if public sewer is / r available within 200 feet.) Installation will serve: Residence Commercial ✓ Other J� fat Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK Le-,Type/Mfg CapacityNo. Compartments 2— PKG. TREATMENT PLT. fu- Method of Disposal Distance to nearest: Well.1 !_ Foundation C" I _ Property Line y0 0 LEACHING LINE 4--No. & Length of lines �� 40 Total length/size_ FILTER BED i--Distance to nearest: Well 13 0Foundation _ 161 Property Line _V 0 0 / SEEPAGE PITS [_Depth _ _Size�;.LD a Number J—_ " SUMPS J � Distance to nearest: Well J-212-f � Foundation —f_ �!� 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."Contractors 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 applicant must call for all r uired inspections. Complete drawing on ,r�everse side. } Signed X /L- Title: � Date: y `� FOR DEPARTMENT USE ONLY Application Accepted by Date Area Pit or Grout Inspection by Date aFinal Inspection by Date Additional Comments: U Stk 466-6781 n Lodi 369-36211 U Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 16,01 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE CK INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY /DATE PERMIT NO. . EH 13-24 IREV. C.f-_�� U EH 1I-Ze