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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 9 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. 1662 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. d Job Address — City r of Size PM Owner's Name ,1,/ 1iyi�.tV Address hone Contractor Mo /ZS � Address License No. > Phone 7 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 FOUNDATION AGRICULTURE'WELL OTHER WELL ( PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA-?CdNSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca ! Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy !Type of Casing Specifications ❑ Public n Other ❑ Delta Depth of Grout Seal lop Type of Grout _ I I Irrigation --- .--,Approx.-DEpth—I..I JEastorn--_�_Surfiace_Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction Well Diameter 1) Sealin`g`Materialztl�p 501 Y,:.R Depth- ,. -l-- -•-•Filler Material-1•Below•50a— �+ � IIr�L]`. TYPE OF SEPTIC WORK: NEW INSTALLATION l l REPAIR/ADDITION i I DESTRUCTION f I (Noiseptic system permitted if public sewer is available within 200 feet.l Installation will serve. Residence_ Commercial_ Other r Number of living units: Number of bedrooms � 3 Y Character of soil to a depth of 3 feet: ater table depth r SEPTIC TANK ❑ Type/Mfg Capacity — W6. Compartments 1 : PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation ' .�� Prope rty L l ijt v f'' LEACHING LINE ❑ No. & Length of lines Total length).,i&- r FILTER BED ❑ Distance to nearest: Well Foundation Prop" rty Liner I I SEEPAGE PITS 11 Depth Size Number i f SUMPS ❑ Distance to nearest: Well Foundation Property Line/ DISPOSAL PONDS ❑ S 'S I hereby certify that I have preparedthis-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 Di$trict. DC7 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, 1 shall not I employ any person in such manner as to become subject to workman's compensation laws of California."Contrac'tor`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 pdir�ons subject to workman's compensa- tion laws of California." 1 The applicant27�preplele drawing �n aver/�sidA�� Signed X Title: k Date: u 727Z)1ex R DEPARTMENT USE ONLY I s r ry Application Accepted by — Date 1 1 Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: ��.��-LX"1 1 Ar-> -_ i�� ! � .,••-,,.,,__ ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazalton-Ave., P.O. Box 2009, Stk., CA,95201 FEE INFO AMOUNT DUE AMOUNT REMITTED ASH RECEIVED BY // DATE PERMIT'NO. JL +.EH 13-2/(REV,i/n 51 S f�� !Uf` �� )�� c' J EH 11-26 �4 /