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' Y APPLICATION .FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON 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. 1962 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. f Joh Addressz 51,z/ Q City 7J_�J Lot Size X 3 6 PM I. Owner's Name "—Address � Phone Contractor's Name � � 1�// L cl ense NN Phone TYPE OF WELL/PUMP: NEW WELL ❑ .j *WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ U DISTANCE TO NEAREST: SEPTIC TANK . SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION =AGRIGULTURE WEL-L -- OTHER WELL PITS/SUMPS INTENDED'USE- • TYPE OF WELL PROBLEM AREA'CONSTRUCTION SPECIFICATIONS ❑ lndustrial' �e ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing V ; El Domestic/Private ❑Gravel Pack ❑ Tracy-'—"°"'Type of-Casing""' Specifications ❑ Public ❑ Other ; ❑ Delta Depth of Grout Seal ;`, Type of Grout ❑ Irrigation --Approx. Depth , El Eastern Surface Seal Installed by. ' I Repair Work Done ❑ Type of Pump r H.P. State Work Done Well Destruction ❑ Well Diameter I Sealing Material-itop-501' Depth I � TFiller Materia a'I IBe w 60'1 TYPE OF SEPTIC WORK: NEW INSTALLATION V REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence= Commercial= ther s C 5 Number of living units: Number-of bedrooms 0 Character of soil to a depth of 3 feet: —r,#R A/9,0Y Water table depth SEPTIC TANK Type/Mfg S'tapaeity 1.2_60 No. Compartments PKG. TREATMENT PLT. ❑ a r Method'of Disposal '.,Distance to nearest: Well--zV—,& Foundation /40 Property Line �6 LEACHING LINE No. & Length of lines Total length/size FILTER.BED ❑ Distance to nearest: Well Foundation Property Line ct.—, f `SEEPAGE PITS .❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that`fhave 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. . bI t 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."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." The applicant all for all required inspections.. Complete drawing on reverse sl Signed Title:- Date: FOR DEPARTMENT USE ONLY Application Accepted by Date 6 Are D Pit or Grout Inspection by Date 4Final Inspection by " °2 y r'•'f �Ddte Additional Comments: +��'S`��J G/Vf 42W 11! is 21 ❑ Stk 466-6791 ❑ Lodi .369-3621 ❑ Mant ca 823-7104 ED Tracy 835-6395 Applicant- Return all copies to: Environmental Health PerMft%SerVidWs1601 E. Hazelton Ave—. P.O. Box 2009, Stk., CA 95201 FEECKINFO AMOUNT DUE AMOUNT REMITTED :CASH, ti RECEIVED'BY��<t: GATE PERMIT`N0. +EH13-24 1REV.10/831 EH 14-25