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F APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E..HAZE T ON AVE.,.STOCKTON, CA Telephone (209) 466-6781 l; PERMIT EXPIRES 1 YEAR FROM DATE ISSUED fit IT'. 1141 (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 a Local Health District: Job Address [twAnb. -City ��TC7 of Size PM JOwner's NameNn,-Address VL`P Phone ( �A 1 Contractor c ULV��Sddress 07 a C1 _ F-Gi..<L License tVo. r6 Phone TYPE OF WELL/ MP: NEW WELL ❑ WELL°'REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ !SYST.EM,REPAIR❑' OTHER ❑ DISTANCE TO NEAREST: SEP,TIC,.TANK I SEWER LINES �� DISPOSAL FLD. PROP. LINE N FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS lO i INTENDED USE TYPE OF WELL PROBLEM AREA' CONSTRUCTION SPECIFICATIONS ❑ Industrial' ❑ Open.Bottom ❑ Manteca # Dia- of Well Excavation Dia- of Well Casing 1 ❑ Domestic/.Private c:. D Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Gfout Seal Type:of Grout ❑ Irrigation ---Approx.,Depth ❑ Eastern ' ' Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. _ State Work Done_ _—_- -`-r dj d Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below.501 TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑, DESTRUCTION ❑ (No septic system permitted.if public sewer is -' available,within 200 feet./ " Installation will serve: Residence X Commercial_ Other Number of living units:2 Number of,bedrooms : 'y Character of soil!to a'depth of vest: 40 J _ Water table depth_ C> d SEPTIC TANK; of ,� < „Type/Mfg I4 1 Y Y Capacity ZrLbQ -No.,Compa"ntst �. n,.k ,y-`_ _ PKG. TREATMENT' PLT. ❑f Method of.Disposal Distance to nearest: Well es Foundation 4 0 Property Line LEACHING LINE No. & Length of lines �r t i Total length/size r r X FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS �9 Depth Size � 3>1 Number SUMPS Distance to nearest: Well Foundation b� Property Line�"I 0 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 S rules and regulations of the San Joaquin Local Health District. Y" c < !-= 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 subcontracting 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 ust call for all r d spections. Complete drawing on reverse side. �( Signed X Title: �P�, Date: FOR DARTMENT USE ONLY Application Accepted by aAti ��a 0 Date �T }a Area Pit or Grout Inspection by TqZK�a? Dategf=1021� - Final Inspection by .�o, _ N� Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 8355-6385 i Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 955201FEE 1 INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMWNO, +'EH13-24(REV.I/A t) - I. ' EH 1428 -7Q` C� St[d �� j ^�� r