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i APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T 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 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. 11362 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. /,��f� Sir Job Address + City Lot Size PM Owner's Name 1/ c ��460 Address Phone Contractor 2� 7r� License No.�� Address �� 5�f�� Z6�t5 Phone TYPE OF WELL/PUMP: f NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE .I TYPE OFx.WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 0 Industrial 0 Open Bottom ❑ Manteca Dia. of Well Excavation 'Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications Ul Public Cl Other r Cl Delta Depth of Grout Seal Type of Grout . t `, ! t W I I Irrigation _..Approx. Depth I I Eastern Surface Seal Installed by _ i Repair Work Done ❑ Type of Pump H.P, State Work Done 4 Well Destruction ❑ Well Diameter Sealing Material (top 50') 14 E 4 Depth Filler Material (Belo 501 TYPE-OF"SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR/ADDITION DESTRUCTION I 1 (No septic system permitted it public sewer is = available within 200 feet.) Installation will serve: Residence mmercial her Number of living units: _71/__ Number of bedrooms Character of soil to a depth of 3 feet:--=.-. �QF Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ �s?��`r�f Method of Disposal Distance to nearest: `Well / Foundation Property Line r 4 LEACHING LINE No. & Length of lines I' Total length/size FILTER BED ❑ Distance to nearest: Well ./'Oer 74-- Foundation X094 ' Property Line - Z d 7`` ' 1 SEEPAGE PITS -1 Depth2 _ -Size_ _ Number SUMPS [--IDistance to nearest: Well' lQd 74- Foundation 3 �m Property Line o T DISPOSAL PONDS ❑ i 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 Di1trict. r - ---- 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-fining 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 applicant must foLall uir pections. Complete drawing on reverse side. '+ 6� Signed X Title':`--- � ��L '' Date: FOR DEPARTMENT USE ONLY y t Application Accepted by ''Date "�� .,r Area ! ` Pit or Grout Inspection by Date Final Inspection by Date Additiorial Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 623-7104 4 ❑ Tracy 835-&385, - Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009; Stk., CA 95201 L FEE INFO AMOUNT DUEL AMOU T REMITTED CASHif RECEIVED 9Y DATE � PERMIT'N�O, s.EH1$-24{REv.Fi K51 / Q yrS�2& EH 14-29 i