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1 9 APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA ., Telephone (209) 466-6781 y 1 H 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 her in 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 eigulations of the San Joaquin L4)cal Health District. Joh Address —Z I City Lot Size PM .. _I . .. Owner's Name Address ^� � Phone 2 C31 - Contractor's Name egi�Idotf Vf XLIA"T License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ ~� . PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER, L" ' DISTANCE TO NEAREST: SEPTIC.TANK SEWER LINES DISPOSAL FLD. '�tl PROP. LINE. ' FOUNDAtidN""'i4GR1Cl1LTlJRE'►)Yfi:L� OTHER WELL " PITS/SUMPS :,� _ �4� INTENDED USE 5 TYPE OF WELLt--1 ROBLEM AREA--CONSTRUCTION SPECIFICiATIONS--` I ❑ Industrial_. M—Open Bottom ❑ Manteca Dia. of Well Excavation ! Dia. of Well Casing (❑ Domestic/Pri�ate__--O Gravel Pack ❑ Tracy Type of Casing 3 Specifications ❑ Public `0 Other ❑ Delta Depth of Grout Seal ( Type of Grout- ❑ Irrigation �Approx:Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump j N.P. State Work Done ISJ f Well Destruction'!, ❑ Well Diameter Sealing Material (top 501 i i Depth ` Filler Material'iBelow'50')- I TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic syst0 f em permitted if public sewer is available within 20eet.) sw I _Installatlon will serve: -Residence; Commercial— Other Number of living unite: Z✓� Number of bedrooms Character of soil to a de�ptthh`'of 3 feet: - � � ;.� _a/9 Water table depth 0 SEPTIC TANK !� 2 'IType/Mfg Capacity /ZOD No. Compartments PKG. TREATMENT PLT. ❑ I r Method of Disposal /T 1 Dlatance to nearest: Well p Foundation Property Line Z_D& I t LEACHING LINE" :No. & Length of linos Total length/size FILTER SED ._� � _ ❑ ?Distance to nearest; Well [5"`0 Foundation s� Property Line SEEPAGE PITS W', -Z Size �3 Number ' SUMPS d ❑_4�`Dlstsnce-to•neerest:T - Well 4016 f -Foundatio .E 4 Property Line DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work 41,be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health Distridi ` ` I 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 Ism of California."Contractor's hiring or sub-contracting signature certifies the following:"I certffy that to the performance of the work for which this permit Is issued,l shall employ persons subject to workman's compensa- tion laws of California." +• ` The applica call for all r ul d In fictions. omplete drawing on reverse ld Signed Title: Date: 4 ' FOR DEPARTMENT USE ONLY Application Accepted by Data. ` � Area = fIt Grout Inspection by Dab Final Inspection by Date S� Additional Comments: ❑ Stk 4664MI ❑ Lodi 319.38'21 ❑ Manteca 823-7104 ❑ Tracy 83640M Applicant- Return all copies to: Envlronmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 INFO AMOUNT DUE. AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT"N0. + :H I=(REV.10/a33 �_F4