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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE i ON AVE., STOCKTON, CA Telephone 12091 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED i� (Complete in Triplicate) is � : Application is hereby made to the San Joagwn 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 weii/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address ` Al, t Qa/ City Lot Size/w, x PM t /Y �' { Owner's Name a dress Phone d' 3 Phone- 712 Contractor Address 1Litense No.�_.�L(Q TYPE OF WELL/PUMP: NEW WELL F1WELL REPLACEMENT El DESTRUCTION El PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS `V ' INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 1(�] ❑ Industrial D Open Bottom ❑ Manteca Dia- of Well Excavation ` Dia. of Well Casing vl Specifications E] Domestic/Private 171 Gravel Pack El Tracy Type of Casing - M Public F1 Other F1 Delta Depth of Grout Seal Type of Grout I 1 Irrigation Approx. Depth ( I Eastern Surface Seal Installed by - Repair Work Done ❑ Type of Pump H.P. State Work-Done _ Well Destruction ❑ Well Diameter t Sealing Material (top 501 C_ Depth } Filler Material (Below 501 — � TYPE OF SEPTIC WORK: NEW INSTALLATION ly REPAIR/ADDITION l.1 DESTRUCTION i I (No septic system permitted if public sewer is { available within 200 feet.) Installation will serve: Re 'dente ' Commercial Other Number of living units: Number of bedro ms 7 Character of soil to a dep h of 3 feet: Water table depth" SEPTIC TANK [ Type/Mfg apacity 2d V No. Compartments PKG. TREATMENT PLT. ❑ ,\\ ( Method of Disposal I ±J f Foundation Property Line Distance to nearest: Welf 1/� P Y i LEACHING LINE No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Weil Foundation --lam— Property Line J7 l f SEEPAGE PITS l Depth Size Number SUMPS 1 Distance to nearest: Well o � 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 app)' an 5t call r all r q ins oris. ompl to draw' g on reverse side. Signed X -tie Date: FOR DEPARTMENT USE ONLY -� - Application Accepted by Date�}-_ 1 9CI AAArea Pit or Grout Inspection bye/ Date Final Inspection by Date Additional Comments: Va� �d ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 523-7104 ❑ Tracy 835-6385 Applicant P Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED ASH RECEIVED BY DATE PERMIT NO. C INFO �"� H r.EH 13-24(REV.sins) /a 'J /�/] LP ;V-J7 "' EH t4-213