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4 . .� APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEr_.TON AVE:, STOCKTON, CA. _ -Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED i (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. 5-+S �„ .. 'r. Y•+ , Job Address _C ` .12/113-6 s City Lot Size PM P 'aft♦ y •i ' r -::1 r Owner's Name- //b CJIe�'2eat�fl7 Address l Phone. Contractor Address License No.c2>b5 15� Phone —TYPE-OF-WELL/PUMP;:-- -'- ---NEW-WELT-U—""—WELL REPL'A'CEMEIW ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE \} "rv—FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS 1`'` INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCT ION;SPECIFICATIONS �! t ❑ Industrial � ❑ 9peh Bottom.,� ❑ Manteca Dia. of Well Excavation Dia. of Well Casing :V ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications i ❑ 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. a ' 'State Work Done_ Well Destruction ❑ Well Diameter Sealing Material (top 50') t DepthFiller Material (Below 501 l TYPE OF SEPTIC WORK: NEW INSTALL''ATIO fREPAIR/ADDITION ❑ DESTRUCTION ❑ iNo septic system permitted if public sewer is `available within 200 feet.) yInstallation will serve:-,,..Residence Commercial b the' Number of living units: 140nber of bedrooms Character of soil to a depth of 3 feet: s �: Water table depth SEPTIC TANK_ „Type/.MfgCapaci f ty No. Compartments PKG. TREATMENT 7Lf_�'f `' �± Method of Disposal ADistance to nearest: Well. Foundation� Property Line -%' LEACHING LINE _ No. &xLingth ofilines �� :" Total lengthlsize 1PVT- 0 �,� FILTER BED' I ' ❑`'Distance to nearest: Well Foundation ��€ 'Property Line— ...— } Al: k.: . 71t SEEPAG4.tPI7SE .�j EJ6epth } lie _ I Number SUMPS -_-�-____ E ❑ Distange to nearest:' ','-Well Foundation g Property Line `i DISPOSAL PONDS ❑ €•- � a � ,r� , _ � „ f l I hereby certify that I have prepared J'iZapplication+and°ihat the work will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations offthe-San Joaquin:Local Health District. Home owner or licertssed ag"Vs signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not employ any perso'in such manner as to-become subject to workman's compensation laws o'f California.".Contractor's hiring or sub-contracting signature certifies the following•"I certify that in the performance of the work for which this permit isi issued,I shall employ persons subject to workman's compensa- tion laws of California " The applicant must call f all r ;iced inspections. Complete drawing`on reverse side. Signed X 14p, Title: ��_ Date: _ / FOR DEPARTMENT USE ONLY r Application Accepted by / Date b _92 Area Pit or Grout Inspection by f Data Final Inspection by Date Additional Comments: ❑ Stk 466-6781 . ❑ Lodi 369-3621 ❑ Manteca 823-7104 VTracy 835-63$5 Applicant- Return all copies to: Environmental Health Permit/Services 1601 C. Hazelton Ave., P.O. Box 2009, Stk' CA 95201 FEE INFO AMOUNT DUE' AMOUNT REMITTED CASH RECEIVED BY;'.'CK DATE PERMIT NO. + EJ1}Z4(AEV,1i85) A --- EH 14-26 : '� a Ip. ��O 1_• .