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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 madeio the San Joyaquin 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-' „f Job Address.- r! N/�' i � 4�r City 6 QJ0 Lot Size!''� " 1 C_PM � r. Owner's Name. �/ Z Address / /f��/(�7� __ ' Phone Contractortell I jk/,rA OA.1 dress Av, c_` License EVd'-'3(533�_Phone ,_&JZc F 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 PETS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS L ' ❑ Industrial "�-❑ Open Bottom El Manteca Dia. of Well Excavation Dia. of Well Casing 4 © Domestic/Private 0 Gravel Pack 0 Tracy ,. Type of Casing Specifications 5 ❑ Public Cl Other n Delta li;� i Depth of Grout Seal Type of Grout — I E Irrigation —.-Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done 17� Type of Pump H.P. State Work Done Well Destruction ID Well Diameter Sealing Material (top 501 ` Depth Filler Material {Below 501 v TYPE OF SEPTIC WORK: NEW INSTALLATION . REPAIR/ADDITION l I DESTRUCTION 1 I (No septic system permitted if public sewer is i available within 200 feet.) Installation will serve: Residence i Commercial Other " Number of living units: Number of b'drooms Y Character of soil to,a depth of 3 feet: - Water table depth SEPTIC TANK ❑ "Typ M f /�r4.v�►f u= ` 'Capacity O No. Compartments �\ Ol PKC- TREATMENT PLT. ED s ` Method of Disposal Distance to nearest: Well F4ndation r Property Line QS LEACHING LINES Cl No-.& Lengih of lines /4"d" r Total length/size r FILTER BED ` ❑ Distance to nearest: Well �¢ f Foundation// Property Line X12 SEEPAGE PITS }i I Depth "' Size Number SUMPS f LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 46 1 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 performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of Cali ia." The applican ust all for all requi d ins tions omplete drawing on r Jarse side. r Signed XTitle: FOR DEPARTMENT-USE ONLY / Application Accepted by Date �i Area f L Pit or Grout Inspect{ y Date Final Inspection by k Date ��Ll r Additional Comments: 0 Stk 466-6781 ❑ Lodi 369-3621 0 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 MOUNT DUCE AMOUNT REMITTED K RECEIVEDBY DATE PERMIT'NO. INFO CASH r-.7 k1 Ll EH t/-28 `J �� f" /�f - t EH 13.21(REV.v Z K 5] / t / a