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` APPLICATION FOR PERMIT SAN JOAQUIN LOCAL`HEALTH DISTRICT f 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466_6781 PERMIT EXPIRES 'I 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 Local Health District. for well/pump and the Ryles and Regulations of the San Joaquin V Job Address /7/OO (y}�f �740� City Lot Size ".tea. Sox �7z-oS - PM ;I Owner's Name Address 21 -1y'•rp., I/q � Z�/, Phone 4zo q3 Contractor�i¢t�E� s� -r�,t rAddress !�'d O ,sl 4 fZ_O- License No.53333 / Phone /-.Yo 3 TYPE OF WELL/PUMP: NEW WELL ❑ '—WEL'L-REPL"ACEMENT'❑�' '�-DESTRGCTION-❑""" � I PUMP INSTALLATION ❑ SYSTEM REPAIR_❑ OTHER ❑ ` DISTANCE TO;NEAREST: SEPTIC TANK SEWER LINES Ilk DISPOSAL FLD. PROP. LINE. FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS r INTENDED USE TYPE OF WELL PROBLEM AREA `CONSTRUCTION SPECIFICATIONS ❑ industrial ❑ Open Bottom ❑ Manteca Dia. Of Well Excavation Dia. of'Well Casing ❑ Domestic/Private El Gravel Pack ❑ Tracy � Type of Casing Specifications ,- ❑ Public ❑ Other,, ❑ Delta Depth of Grout Seal �+ EJIrri Irrigation Type of Grout 9 --Approx. L] Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H p . State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50') ` TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if publie-sewer is available within 200 feet.) ° Installation will serve: Residence Commercial 4-1 Other '" Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: ' ^" SEPTIC TANK XI Type/Mfg d�mc �/L �y Water table depth r g /1 T-/ � *acity CaOC No. Compartments ' \ PKG. TREATMENT PLT. ❑ Method of Disposal - Distance to nearest: Well FoundationProperty Line LEACHING LINE 1 No. & Length of lines M 00 Total length/size FILTER BED ❑ Distance to nearest: Well &-6 Foundation_� 0 f Property Line 2.0 SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundationf Property Line i' N '3 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`subjeat to workman's compensa- tion laws of California." The applicant must call for all re wired inspections. Complete drawing on reverse side. Signed X Title: f Date: 1 "� .� FOR DEPARTMENT USE ONLY �7 Application Accepted by r +Date / a�� 13 ' Area Pit or Grout Inspection by 'IV Date Final Inspection by r Date /y'} 3 000 a.Q !C �- yoo r -hr 1DD P fo' ee � ` Additional Comments: n�D0 _J. F ❑ Stk 4666781 ❑ Lodi 3621 ❑ Manteca 823-7104 ❑ Tracy. 835-6385-tan ux Applicant- Return all copies to: Environmental Ith Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 9b C)0 O r * o � s �-_ � FEE INFO AMOUNT DUEAMOUNT REMITTED CK RECE ED BY r CASH DATE -EH 13-24(REv.1/s 5) EH 1426