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i APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT s 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone {209} 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED I I (Complete in Triplicate) Y 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. lob Address �' rn{1�QC City Lot Size PM Owner's Name W II N * �- A 1�C �_ ddress u� � 8 23 r� Contractor 1'"[��v ` jA_ � CY'`� Address LATW-Vicense No. ��Phone 8-65-731q 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 d x FOUNDATION AGRICULTURE WELL'- OTHER WELL PITS/SUMPS C i INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack © Tracy Type of Casing Specifications 'I Public Cl Other n Delta Depth of Grout Seal Type of Grout 1 1 Irrigation -Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done r Weil Destruction ❑ Well Diameter Sealing Material (top 501 6 Depth Filler Material (Below 501 —_ TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR/ADDITION 1.1 DESTRUCTION (No septic system permitted if public sewer is [' available within 200 feet.) Installation will serve: Residence_ Commercial_____ Other Number of living units: Number of bedrooms , Character of soil to a depth'of 3 feet: f Water table depth SEPTIC TANK ° ❑ 'Type/Mfg Capacity No. Compartments 1 PKG. TREATMENT PLT. ❑ 4 " ° r Method of Disposal Distance to nearest: Well Foundation= Property Line LEACHING LINE ❑ No. & Length of lines Total length/size I� FILTER BED ❑ -;Distance to nearest: Well Foundation` Property Line SEEPAGE PITS I I Depth t Size ¢ Number SUMPS ❑ Distance*to nearest: Well Foundation Property Line ` DISPOSAL PONDS ❑ M .._..k 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. # r 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, t shall not employ any person in such manner as to became 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 is issued, I shall employ persons subject to workman's compensa- tion laws of California." ,1 The applicant must all for all required inspecti f s. Complete drawing on reverse side. t Signed X Title: r bl. Irk-ey'L Date: 101 vV� SSS F DEPARTMENT USE ONLY (� Application Accepted by 611,#_ADate v Area 17 Pit or GrouYlnspection by Date Final Inspection by Date Additional Comments: I ❑ Silk 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 FEE AMOUNT DUE AMOUNT REMITTED CK 11 RECEIVED BYDATE PERMIT_NO. INFO CASH +.EH 13.241REV.I Hsl e, j��'✓ — ��. 1D(IU EH 14-28