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Mt, : APPLICATION FOR PERMIT i SAN JOAQUIN LOCAL HEALTH DISTRICT k 1601 E. HAZELTON AVE., STOCKTON, CA I Telephone (209) 466-6781 p 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.Nos549 for sewage or,No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Ad-dress L!Q� I jj_ City 2 `• of Size PM Owner's Name IL/ A . Lock ddresse-0-i 44UA4a, Phone!,�/ Contract�i.k Address 5P License Phone TYPE OF.,IWELL/PUMP: NEW WELL U --,,,:WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION )Q SYSTEM REPAIR ❑ OTHER ❑ / DISTANC, TO NEAREST: SEPTIC TANK �c44� SEWER LINES DISPOSAL FLO. PROP. LINE /Q g� FOUNDATION a AGRICULTURE WELL OTHER WELL' '�O t PITS/SUMPS kr INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS © Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavatio Dia. of Well Casing )AQorn 41c/Private ((Gravel Pack' ❑ Tracy Type of Casing ifications L M Public I ❑ Other n Delta Depth of Grout Seal a of Grout _ ;.3 I I Irrigation —.-Approx. Dep l I Eastern Surf ce Seal Installed by Repair Work Done ❑ Type of PumppF„ d1.` H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50.1 f 111 Depth Filler Material (Below 501 + _ TYPE OF SEPTIC WORK: NEW INSTALLATION I l REPAIR/ADDITION I I DESTRUCTION I 1 iNo septic system permitted if public sewer.'is t available within 200 feet.) lnstallatian will serve: Residence ! _ Commercial_ Other �pl Numberlof living units: Number of bedrooms Character of soil to a depth of 3 feet: ; s Water table depth + SEPTIC TANK C Type/Mfg Capacity No. Compartments 7 PKG. TREATMENT PLT. ❑ � - T-- F' -- J1 Method of Disposal t Distance to nearest: Well Foundation Property Line ` LEACHING LINE ❑ No.'& Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGEkFIPITS I I Depth 4 Size Number SUMPS �E� ❑ Distance to nearest: Well Foundation ! Property Line I 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 Di§trict. ' g 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.” Contractor's 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." f` The applic�an ust atl for all r wired inspe tions. Complete drawing on r verse side. 1 ' Signed XIF' date: I � TMENT USE ONLY �( Application Accepted by Date t� � Area Pit or Grout Inspection by Date f Final IInspection by�` Datet Additional�Comments: C� /J� f Ur Lam_ C_U ❑ Stk 466-6781 ❑ Lodi 36,4-36il ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant'.`Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 96201 FEE INFO AMOUNT DUE j AMOUNT REMITTED K RECEIVED BY DATE PERMIT'NO. + EH13-24(REV.1 6) + ` 6 'nb I—C EH 14 26 "14_d0 1 n 17 !