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'E { APPLICATION FOR PERMIT SAN JOAQUIN"LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 r PERMIT EXPIRES 1'YEAR FROM DATE ISSUED II (Complete in Triplidate) 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 Regulations of the San Joaquin Local Health District. i Job Address G ' aV V 001 City 5_11 Lot Size is Owner's Name Ad• L7� 6� Address Phone 1 O,ar License No. ' Phone Contractor �. �� - Address TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR � . OTHER ❑ LJ f 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 ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Weli Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications F1 Public ❑ Other l=1 Delta Depth of Grout Seal Type of Grout I ! Irrigation I._Approx. Depth i I Eastern-Ilk Surface Seal Installed by Repair Work Done ❑ Type of Pump" H.P. t State Work Done!— Well oneeWell Destruction ❑ Well Diameter Sealing Material (tap 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIRIADDITION t l DESTRUCTION t.1-(No septic system permitted if public sewer is; x _ } ,# _ available within 200 feet.) . 1 Installation will serve: Residence Commercial Other Number of living units: Number of bedrooms fo Character of soil to a depth-of 3 feet: (V A Water table depth SEPTiC TANK ElType/Mfg C l — Capacity_ �DO' No. CompartmentsPKG. TREATMENT PLT. ❑ Method of DisposalDistance to nearest: Well AV Foundation 1Property Line _ F- i LEACHING LINE Mo. & Length of lines `+ Total length/size 'Z��'• � ' FILTER BED ❑ Distance to nearest: Well�Q�__ Foundation 25-** Property Line 1 w SEE=PAGE PITS l I 'Depth Size _ Number SUMPS L1 Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ ' I hereby certify that l 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. 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 parson in such manner as to become subject to workman's compensation taws 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,1 shall employ persons subject to workman's compensa- tion laws of California." The applicant must cal for all required inspections. Compiete drawing on reverse side. Signed X Title: Date: FOR AEPARTMENT USE ONLY Application Accepted by Date ✓ r Area / + •• Pit or Grout Inspection by Date Final Inspection by I p r Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 923-7104 O Tracy 835-6385 . Applicant- Return all copies,to: Environmental Health Permit/Services 1601 E. Hazelton Ave., f.0. Box 2009, Stk., CA 95201 I FEE k (NFD AMOUNT DUE AMOUNT REMITTEp C SH RECEIVED BY DATE PERMIT ND. w EH 13-24(REV.1/A 5) EH 14-20 - VVV