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1 APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE ON 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 constrilct and/or instaH 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. Job Address - — City Lot Sire PM Owner's Name = X_— Address - 1�?_ —.Phone -,Contractor . 1,_„( LCL=C� Address 2 6_ /-4” __License No Phone77-cic TYPE OF WELL/PUMP: NEW WELL F1 WELL REPLACEMENT ^1 DESTRUCTION U l —PUMP INSTALLATION n SYSTEM REPAIR;. ,OTHER L' DISTANCE TO-NEAREST: SEPTIC TANK SEWER LINES _ --,DISPUSAL-FCD- • -PROP...Ll}IE FOUNDATION AGRICULTURE WELL _ _ OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Industrial I I Open Bottom !J Manteca Dia. of Well Excavation Dia. of Well Casing C!_Domestic/Private_ Gravel Pack _ ❑ Tracy, Type of Casing-- Specifications \ Public i I Other i Delta Depth of Grout Seal _ _ Type of Grout l'I Irrigation --Approx. Depth 171 Eastern Surface Seal Installed by F Repair Work Done i=. Type of Pump H,P. — State Work Done Well Destruction r] Well Diameter _ Sealing Material Itop 501 _. Depth -k ' Filler Material 18elow 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION i : DESTRUCTIO INo septic system permitted N public sewer is available within 200 feet.l Installation will serve: .Residence. Commercial __ Other Number of living units: _ _ Number of bedrooms. _ Character of shil to a depth-of 3'feet _� _-. _Water table depth�..� SEPTIC TANK ❑ Type/Mfg Capacity_ - ._ No. Compartments PKG. TREATMENT PLT. i : ' Method of Disposal Distance to nearest" 'Well _ Foundation Property Line r r� LEACHING LINE No. & Length of lines — _ Total length/size FILTER BED C, Distance to nearest: Well Foundation _ _ Property Line _ I i SEEPAGE PITS ❑ Depth __Sue Number_ o SUMPS - Distance to nearest: Well Foundation_ _ Property Line DISPOSAL PONDS a 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 tollowing: "I certify that in the performanri 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 compensatkxi'laws of Calitomia."Contractor's hiring or sub-contracting signature certifies the Iohowing: "I certify that in the performance of the work for which this permit is issued. I shah employ persons subject to workman's campensa- tion laws of California." The applicant must c7forZired inspections. Complete drawing on reverse side. S Signed XTitte::_. —rte '�t�/ Date: _,'A�, � _ } �R DEPARTMENT USE ONLY Application Accepted by _ r' Date "� Area Pit or Grout Inspection by �I Date Final Inspection by Date Additional Comments: z2() ❑ Stk 466-878] ❑ Lodi 3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 + i Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazefton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE +AMOUNT REMITTED CK rt _ - RECENED SY DATE PERMIT*NO. 1N �� 4 C (�/�' �H /1'� �rEN13-24CAEV.+'ass . C1�..J t !,J• "•' 1663 Z �" —�u �� t � EH 14-2a