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i; APPLICATION FOR PERMIT ' SAN JOAQUIN LOCACHEALTH DISTRICT l 1601 E. HAZEL T ON AVE.; STOCKTON, CA Telephone_(209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED rz , Ip ..(Complete in Triplicate.) h.. ,t:. 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 ` r Job Address 'City �O�—Lot Sizeley PM Owner's Name 1Vlr e ` ddress AV ✓c. sL a- it Phone Contractor Address r dd License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ ' SYSTEM REPAIR �; OTHER ❑ VVV' DISTANCE TO*NEAREST: SEPTIC TANK SEWER LINESf DISPOSAL FLD.' PROP. LINE - 1J FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION,SPECIFICATIONS ❑ Industrial �� ❑ Open Bottom ❑ Manteca Dia. of Well Excavation � ;� p ` Dia. of Wel! Casing Domestic/Priva.te ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public . Q Other ❑ Delta Depth of Grout Seal ; r Type of Grout Ll Irrigation —Appsox.,Depth Eastern S ace Seal Install d b`yt !f Repair Work DoneType of Pump H.P� A' - ► �, ` _ S3ate Work Done 0. i Well Destruction: ❑ Well Diamete Sea ngMaterialqtp 501 f jF Depth — Filler Material (Below 501 TYPE OF SEPTIC:WORK: NEW INSTALLATION LIREPAIRlADOITION ❑ IDESTRUCTION ❑ iiNo septic system permitted if public sewer is available within 200 feet.) Installation will'serve: Residence,= Commercial—1other-"" t zNumber of living units: Number of bedrooms Character of soil to a depth of 3 feet T - ,��` "'-"""" Water table depth i SEPTIC TANK ❑ Type%Mfg Ii f Capacity f No. Compartments PKG. TREATMENT PLT. ❑ 1i' r )I1 f i Method of Disposal Distance to nearest: Well Foundation Property Line r f , ,3 l � �'-✓a tir��l LEACHING LINE ❑ No. & Length of lines 9 � Total length/size FILTER BED 171Distance#o nearest: Well Foundation Property Line �� J SEEPAGE PITS I Cl' Depih•�' i Size Number t SUMPS ❑ DistanceJoi nearest; Well Foundation Property Line r 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. �I Home owner or licensed agent's signature certifies the following: "I certiNy 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." # j: ?l• The applican call for all requ' inlis spe . Co late drawing on''II reverse side. Signed X u Title: Data: A:) -2 > AI FOR DEPARTMENT USE ONLY Application Accepted by Date 2 a Pit or Grout Inspactio i � Date Final Inspection by D /o 3 Additional Comments: I a ❑ Stk 466-6781] El Lodi 369-3621 ❑ Manteca 823-7104 �� ❑ Tracy 835-6385 - Applicant - Return all copies to: Environmental Health Permit/Services 1601E Hazelton Ave., P.O. Box 2009, Stk., CA 95201- INFO FEE AMOUNT DUE AMOUN�AEOTTED,' CASH% t RECEIUED`BY?-� DATE PERMIT NO. c '+ EH,13-241REV.tiHs1 �� " EH 1428