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R APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT - 1601 E. HAZE 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. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. g 14C Job Address 4PO/ ,4.4 YC 4P0-P b, City� A-m-91EAof Size -41 PM 1.Owner's Name Address ✓�%W b .4J�r//ARPhone Contractor �J�LlL Address Q._ IVY �� License No.�`yd� Phone J TYPE OF WELL/PUMP: NEW WELL ❑ �y`y WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMPINSTALLATION ❑ SYSTEM REPAIR"❑ _ --OTHER ❑ DISTANCE TO NEAREST: SEPTIC.TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION' AGRICULTUWWELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL, _ --PROBLEM AREA-CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑tOpen Bottom.. :❑ Manteca t'Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ClLGravel Pack �� ❑ Tracy Type of Casing ,Specifications f`l Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout , I I Irrigation _Approx'Depth l I Eastern r ' Surface Seal Installed by t Repair Work Dane `❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 °. Depth Filler Material,(Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I'1 REPAIR�ADNTION DESTRUCTION I 1 '('No'septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_-.,Commercial_ Other b Number of living units: ___a_._ Number.of bedrooms _ r f7111--4 Character of soil to a depth of 3 feet: s'�/ � Water table depth —�. SEPTIC TANK ❑ TWtMfg"""'""' "� ��` Capacity No. Compartments PKG. TREATMENT PLT. ❑ if `.r'{ r Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE l/ No. & Length of-lines �"'//lA Total length/size -t3 'fi FILTER SED ❑ Distance1b nearest. Well =-1--rFdundation_10 Property Line_l_6 1'7 o% SEEPAGE PITS t I Depth.j,�) _Size Number SUMPS ❑ Distance to nearest: Well `Foundation Property Line DISPOSAL PONDS ❑ 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 San Joaquin'Local Health District. _ 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.;; Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the`lperformance of the work for which this permit is issued,-1.64611 employ persons subject to workman's compensa- tion laws of California." The applicant must call for all required inspections..Complete drawing on reverse-side:— t Signed X ' } Title: Date: FOR DEPARTMENT USE ONLY 3 . F. Application Accepted by f Data ` Area • Pit of Grout Inspection by L r, Date Final Inspection by Additional Comments: __ ❑ Stk 466-6781 � ❑ Lodi. 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: trivironmental Health Permit/Services 1601 E. Hazelton Ave., P.D. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK 4 RECEIVEDBY DATE PERMIT-NO. P INFO ' CA H d .,+ EH 13-24 IREV.tine 5l ' �- � _ 69 �,Eti t4-28 u •r - r