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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA ✓J J t Telephone (209) 466-6781 } PERMIT EXPIRES 1 YEAR FROM DATE ISSUED PERNVISERVIOPq �i vLlil�tJlvl�CiV ll'1�j7cli�.5', t (Complete in Triplicate) ' Application is hereby made to the SanJoaquin 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. Jab Address ED City.4.0DI Lot Size PM t Owner's Name ,EO.- F_�'Z _ Address d„2 � U/- Phone Contractor dress _ icense No.0/��--Phone 61,77 TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE -� - - - - FOUNDATIONS - -—AGRICULTURE WELL OTHER WELL -I --PJTS/.SUMP_S-.,*--- ' INTENDED USE TYPE OF.WELL PROBLEM AREA CONSTRUCTION SPECIFICAT NS t i r ❑ industrial E_ Open Bottom ED Manteca Dia. of Well Excavation Dia. of Well Casing Domestic/Private XGravel Pack `❑ Tracy . x Type of Casing C- 7 J AT- 1 Specifications F] Public Cl Other Deltat tDepth of Grout Seal �� Type of Grout I I Irrigation 5a_Approx. DeptW l I`Eastern f 1 Surface Seal Installed by Repair Work Done ❑ Type of Pump H,P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 c Depth I Filler Material (Below 50')'""°'-"- TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is �l I available within 200 feet.) Installation will serve: Residence_ Commercial_ Other x Number of living units: Number of bedrooms j , i. s Character of soil to a depth of 3 feet: Water table depth r SEPTIC TANK ❑ Type/,Mfg/ Capacity t No. Compartments '� J PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line _ �- LEACHING LINE El No. & Leng- th of lines "`Total"lengthlsize FILTER BED ❑ Distance to nearest: Well • 4 "` Foundation Property Line SEEPAGE PITS 11 Depth ' Size _ Number J SUMPS " ❑ Distance to•nearest:.' Well Foundation Property Line DISPOSAL PONDS... . ❑. ,.W _ — - - - - rr - 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 Sain Joaquin Local Health Di§trict. 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 Califoinia."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, I shall employ persons subject to workman's compensa tion.laws of California." The applica i rall r ireins ctions. Complete drawing on reverse side. t +• Signed X Title: r Date: FOR DEPARTMENT USE ONLY Application Accepted by Date Area PitrD peciionFbyaA_gData b /Final Inspection by a e Additmentsk / ❑ Stk 466-6781 L]Lodi-•369-3621 ❑ Manteca 523-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 r K 4 IFEENFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT.NO: a. EH 14-26 EH 13.24(REV.1/14 5) O' 4 . t�