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APPLICATION FOR PERMIT /� F cz / SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON 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 isN 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. f' t Job Address 4 C/ 1" 7— /IIS City J%R Lot Size i0eAZeC004C0 PM Owner's Name C'19 Y< �,�1F� /_,0TQ<0 Address rs�%'�� " =� Phone 4"" Contractor's Name �' "/S/4 1f•-�Ct License Na. Y'" i ' Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ 1 PUMP INSTALLATION ❑ SYSTEM REPAIR ❑, OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES _ DISPOSAL FLD. PROP. LINE i FOUNDATIONAGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE t ZT'YPE OF:WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrials ❑ Open Bottom ❑Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private/ a 11Gravel Pack 11Tracy Type of Casing Specifications ❑ Public ❑ Other I ❑ Delta _Depth of Grout Seal Type of Grout Vi ❑ Irrigation JApprox. Depth ❑ Eastern Surface Seal Installed by OOQ Repair Work Done" ❑ " `Type-_of=Pomp j_H.P. J 4 °�> State Work Dore Well Destruction ❑ Well Diameter YSealing Material (top 501 _Depth` V Filler Material {Below 50'1 r TYPE OF SEPTIC WORK: -NEW INSTALLATION ❑ REPAIR/ADDITION V DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence Commercial_ Other Number of living units: I/— Number of!bedrooms _ Character of soil to a depth of 3 feet: C 4/9 Water table depth 1414 f SEPTIC TANK ,❑ Type/Mfg Capacity 1 No. Compartments } PKG. TREATMENT PLT. LJ,,- 7 # Method of Disposal ' 1 fDistance to nearest: Well Foundation'*-", Property Line LEACHING LINE No. & Length of lines _�- d Total length/size f 1 FILTER BEDS ❑ Distance to nearest: Well_,� G r Foundation,.2 Q Property Line 1 , r� SEEPAGE PITS klDepth j LS�z Size Number} f N SUMPSII+l `❑ Distance to nearest: Well D ° Foundation e'-!? r Property Line DISPOSAL PONDS �❑ z !i I hereby certify that I have prepared this a pplication.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:g g g: "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 Califomia." The applican t call for all required in ctions. Complete drawing on eeverside. Signed Title: Date: FOR DEPARTMENT USE ONLY -� Application Accepted by Ci 3 Area -�,• �,�,� �"—dam/ Pit or Grout Inspection"b"'y`-1, �— Date �¢ Final Inspection by Date } '..Ad `conal Comments: Stk 466-6781 ' ❑ Lodi 369-3621 ❑ 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 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT•'N0. F + EH13-24(REV-70/831 4S . .. ! \- EH 1426 �/I tvf O Li '!&'{ 1-:7-7