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P APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT q 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 I PERMIT EXPIRES" 1 YEAR FROM DATE ISSUED '. (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District fora 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 welUpump and the Rules and Regulations of the San Joaquin Local Health District. Joh Address 4�SA•"�I �Q Uf�� l// - City ��J�T��C.�lLat Size Ano�� PM Owner's Name AV&. _;2_1f ? Address �� t�`a/'�.4�rG Phone j i r7 Contractor / ~%G~� Address /:C�� /�. �5 License No,a L_74�-_Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION D PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK; SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION: AGRICULTURE WELL OTHER WELL PITS/SUMPS 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 _ 1 M Public ❑ Other i Ci Delta Depth of Grout Seal Type of I i IrrigationApprox. Depth I I Eastern Surface Shal Installed by ..:�.. Repair Work Done ❑ Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material (top 501 R Depth ' Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION;I 1 DESTRUCTION I 1 (No septic system permitted if public sewer is ' available within 200 feet.) tA Installation will serve: Residence_A:�11Commercial_ Other 111 � 3 Number of living units: .-I......_.� Number of bedrooms Character of soil to a depth of 3 feet: '' Water table depth SEPTIC TANK ❑ Type/MfgCapacity &,acn No. Compartments i PKG. TREATMENT PLT. ❑ ✓I" !� 7- Method of Disposal • Distance to nearest: Well k_'25_2- Foundation .S Property Line 7— LEACHING LINE ( No."& Length of lines �3--Fft�' 7 Total length/size f � 117— FJLTER BED Ll Distance to nearest: Well��l Foundation / -Property Line <l SEEPAGE PIT.S„_,,,_..,_I_1--Depth- }7 Size” �' Number'' t SUMPS r Cl . Distance to nearest: Well _ " Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that I have prepared this applic tin 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 D3trict. _ 0. Home owner or licensed agent's signature certifies the foilo_wing:.'I-cettify.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 performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." The applicant must call forAl required1rispections. Complete drawing-on reverse side. : Signed X �_� 1 Date: . 9 ��!�—��6 � Title• �.i,- -._ � • �� fi D SE ONLY _. Application Accepted by -t\ Date tea -7, 116f Pit or Grout Inspection by Date Final Inspection by ' r Dated Additional Comments: ❑ 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 INFO AMOUNT DUE E AMOUNT REMITTED y- CASH K 4 RECEIVED BY PATE j' PERMIT NO. .EH 1321 EH 14-26 *