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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZETON 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 I Local Health District. r X73;33 se" 4 +yam tryf99-d Wr9)/ City 1rtc s Lot Size PM Joh Address � Owner's Name �%G ,"yazrf �L�y/t/ g YY Address Jk 333 s0, l��wR-r� +Nlf Phane Contractor's Nrhd/Y `il`'�/+� Address OQ� IfGt,P v &4t'f`, License No.S«!S/ Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑. DESTRUCTION ❑ ?" .,..PUMP INSTALLATION ClSYSTEM REPAIR ❑� OTHER ❑ y DISTANCE TO NEAREST: SEPTIC TANK, SEWER LINES Y J DISPOSAL FLO-. POOP. LINE FOUNDATION AGRICULTURE WELL' OTHER WELL PITS/SUMPS ri INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS. ❑ Industrial ❑ Open Bottom D Manteca Dia. of Well Excavation Dia. of Well Casing EJ Domestic/Private L] Gravel Pack ❑ Tracy Type of Casing Specifications [7 Public F Other- .� - .❑ Delta- 's - - Depth of Grout-Seal �' Type of Grout- 1 I ) Irrigation _ _Approx: Depth t I Eastern Surface Seal Installed by .. Repair Work Done EJ Type of Pump = ,-H.P..-• State Work Done'— Well Destruction ❑ Well Diameter, Sealing Materia"( [top-50') Depth Filler Material (Below 50') REPAIR/ADDITION [ I DESTRUCTION I 1 (No septic system permitted if public sewer is TYPE OF SEPTIC WORK: NEW INSTALLATION l� a 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: I4 `®A Water table depth -f� SEPTIC TANK Type/Mfg 1 r7 AST '` Capacity d d No. Compartments i PKG. TREATMENT PLT. 0f1" r Method of Disposal Distance to nearest: Well 619 Foundation Property Line LEACHING LINE ! _No. & Length of lines Total length/size 4 FILTER BED ❑' Distance to nearest: Well /00 " Foundation Property Line �p I r r , SEEPAGE PITS { I Depth Size ! Number SUMPS ,43]k Distance to nearest: Well Foundation Property,1-ine •5C 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 i 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 performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- r tionlaws of California.' r The applicant m t all for all required inspections. Complete drawing on reverse side. Signed X t:� f, Title: Date: y" a 9� FOR DEPARTMENT USE ONLY r ! 6 gl Area Application.Accepted..byw - - Date - Pitpe or Grout Inspection by Date Final Inspection by- Date - Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 623-7104 ❑ Tracy 635-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEEF INFO A OUNT DUE AMOUNT REMITTED OK RECEIVED BY DATE PERMIT'NOO. +.EH13-241REV.1/x51 SW / [ 149-04 —v ex EH 14'-2e ., t _