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APPLICATION FOR PERMIT 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 is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulatio the San Joaquin Local Health District. Job Address ^�L �r'�' - City��Lot Size —_ PQM( Owner'sNamer �^� 1rT/t/l�/�J�iI!-' clays` 6 Phone Contractor !n Address �a License No. 7Phone_ TYPE OF WELL/PUMP:'`+y .,p NEW WELL ❑ WELL'.REPLACEMENT{.❑ DESTRUCTION ❑ ""'c"" ""PIfiVIP i111STALt�4T10N ❑"��""" SYSTEM REPAIR " J OTHER ❑ VC DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES ,DISPOSAL FLD. PROP. LINE I FOUNDATION AGRICULTURE WELL" ATHER WELL PITSISUMPS F INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRU&104 SPECIFICATIONS 11-industrial LJOpen Bottom y ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private Q Gravel Pack ❑ Tracy Type of Casing eSpecifications M Public ` + ❑ Other i C-i Delta , . "y'Depth of Grout Seal, Type of Grout 11 Irrigation r )t. _-Approx. Depth t I I Eastern Surface Seal Installed by Repair Wok Done El Z'.Type of Pump >H P.y �;- State Work Done_ (� Well Destruction ❑ Well Diameter l�Sealing Material (top 501 # Depth Filler Material-VBelow 50') TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIRIAbDITION DESTRUCTION 11�INo septic system permitted'if public sewer is ! available within 200 feet.) rr , Installation will serve: Residence Commercial_ Qther Number of living units: ___' Number of bedfoorns Character of soil to a depth of.3 feet t Water table depth', 0 j -- '''� -SEPTIC TANK. © Type/Mf( pacity No. Com artnents,j kt y PKG. TREATMENT PLT. ❑ ; 1 a Method of Disposal Distance to nearest: Well "IFounda2ibn� Property Line . k F LEACHING LINE 101-No. &Length of lines Total length/size FILTER,.BER ❑4" Distance to nearest: r"Well—,'�'49.-- F�nd+a"tion Property Line 7 �r SEEPAGE PITS 1 I Depth Size Number r * SUMPS 'r Ll distance to nearest: WellZ 1940 Foundation _- -- Property Lines 1 ;DISPOSAL PONDS . ❑ ` '"� " r 4�' LS,i I'hereby certify that I have prepared this application and that the work will he done in accordance with San.Joaquin county ordinances, state laws, and , rules and regulations of the San Joaquin Local Health Di'strict. 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, 1 shall not employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or subcontracting 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- " ` 1 tion laws of California." The applicant m call for all required ins ctions. Complete drawing on reverse side, Signed64-M!eTitle: /r7 J 9 �� Date: iLzif OR RSR TMENT USE-ONLY Application Accepted by Date" i Area /Prt/or Grout Inspection by MDate -Final Inspection by ate' Additional Comments: ❑ Stk 466-6781 �,�O_Lodi-369-3621 .❑-Manteca•--823-7104——'CD Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 y FEE 'eAMOUfNT DUE `AMOUNT REMIT-TED, 4 CK RECEIVED BY DATE PERMIT NO. " INFO CASH +.EH 1324 1ttEV.1"t 5) � CLQ �'�- Oct EH 14.26 -