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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE` T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES TYEAR 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 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. DRA ^ Z 7 3 � �l-Ca Owner's Name Aress Phone L-91&Address `� �`-��r W-,, 23 ! 3 Phone '94 Contractor f License NO&I TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION C7 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 ',TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIQNS ❑ Industrial a Open Bottom ❑ Manteca Dia- of Well Excavation 5 Dia. of Well Casing ❑ Domestic/ Private C Gravel Pack ❑ Tracy Type of Casing # Specifications i`1 Public F!1 Other 171 -Pelta ?. Depth of Grout Seal Type of Grout _ I I Irrigation ._Approx-99 h.,_wl I.Eastern ,, ,� Seal Installed by_ ! Repair Work Done a /S6rfa'ce Type of Pump i lidi�r�Q H. P. State Work Done Well Destruction ❑ Well Diameter Sealing Material Stop 501 Depth ;''' Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION I1 REPAIR/ADDITION I I DESTRUCTION I I INofseptic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence. Commercial �_ Other Number of living units:L- � 1116 _Number of bedrooms , Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK _❑ ` Type/Mfg ` Capacity No. - - - - J PKG. TREATMENT PLT. ❑ Method of disposal Method 1i Distance to nearest: Well Foundation Property.Line Y. LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ #' Distance to nearest: Well Foundation Property Line SEEPAGE PITS i I Depth Size Number ! ' SUMPS L1,1 Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that I have piepared 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. p 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," 1 The applicant . st call for all r quired inspections. Complete drawing onnreverse , side. 1 Signed XDate: EPARTMENT USE ONLY Application Accepted by i7..�-�1vvtiCau Date 1:-C, Jn Area « Pit or Grout Inspection by Date. ' Final Inspection by�i� l Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 623-7104 ❑ Tracy 835-63$5 - Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 +.EH 13-241REV. i/a5 EH 14-28 FEE INFO AMOUNT DUE AMOUNT REMITTED CA H RECEIVED BY DATE PERMIT'NO. 3 E v y