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I APPLICATION,FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE I ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED f; (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.54.9 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. ` Job Address f 74 11 y _ Ci Lot Size atA_LW 'PM. i Owner's Name Address 'l D Phone PQ $arc 7W4121 3_logS1OS' Contract Address License No, Phone TYPE OF WELL/PUMP: I� NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ 6 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 SPECIFICATIONS ' C ❑ Industrial 1-1 en Bottom ,❑Manteca Dia.`of Well Excavation.. Dia. of Well Casing El Domestic/Private ❑ Gravel Pack ❑ Tracy i' Type of Casing _ a Specifications El ❑ Other i ❑ Delta Depth of Grout-Seal, Type of Grout ❑ Irrigation Approx. Depth ❑ Easternl� _,_—Surface Seal Installed-by. . i Repair Work Done ❑ Typrte of Pump H.P. _ _ _ _ ° ---State Work.Done_ Well Destruction ❑ Well Diameter 3 Sealing Material (top 50') a -_ Depth r Filter Material (Below 50'.) �. TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ DESTRUCTION ❑ 1Noseptic system permitted if public sewer is d available within 200 feet.I - Installation will serve: Residence Commercial Other f Number of living units: :IM. Numbero droo s I Character of soil to a depth of 3 feet: ! t. Water table depth _ A SEPTIC TANK 21"Type/Mfg Capacity 1to0l0 / _ No. Compartments PKG. TREATMENT PLT. ❑ I I f r Method of Disposal Distance to nearest: Well %56 � Foundation 10 y'�hroperty`Line-A5, LEACHING LINE d�No. & Length of lines y0 _Total length/size .X i s ' FILTER BED ❑ Distance to nearest: Well_�50 Foundation .10 Property Line , l SEEPAGE PITS Depth AS Size 33 Number .- , I ,F r - , SUMPS ❑ Distance to nearest: Well 100 Foundation YD Property Line _ 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 District. . %'. , 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 isoissued,I shall employ persons subject to workman's compensa- tion laws of California." I The applicant must call far all rllired inspections. Complete drawing on reverse si ! ,I`e Signed X % 1 Title: V Date: 5_7 } r FOR DEPART- MENT USE ONLY, _,......_ -- Application Accepted by °rv. Date ` �`��- _ Area ,�,: f*--ice�y 1�,!>r+.�k•--)'>+,!- F�/ � /' bitI Grout inspection by �p Date rial Inspection by + Additional 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 IN O KV FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT-N0. + EH13-24{REV.t/g 5S , EH 7426 !I