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r APPLICATION FOR PERMIT L SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON 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 Local Health District. Job Address � � . 2na4LI /�e?S,4� .4P_40 City Lot Size:4 PM ( 10 yAvo Owner's Name G(_L14 [ Address 2!-S2 _!EJ /"/I.(2 4 Phone Contractor Address License No. Phone 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 V_ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS } D Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications f-] Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout-- i rout__I I Irrigation ____..Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done v ` Well Destruction ❑ Well Diameter Sealing Material (top 50') N Depth Fillet Material (Below 501 __ w TYPE OF SEPTIC WORK: NEW 1NSTALLA N I 1 REPAIR/ADDITION DESTRUCTION I } (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_ Other Number of living o units: Number of bedros Character of soil to a depth of 3 feet: .___ ��` ; �� ti _ Water table depth-- SEPTIC epth SEPTIC TANK ❑ TypelMfg Capacity Na. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal 2°/tom.- Distance to nearest: Well Foundation Property Line LEACHING LINE (!LNo. & Length of lines `W Total length/size Ga FILTER BED El Distance to nearest: Well .= Foundation Property Line l SEEPAGE PITS it- Deptht Size Number SUMPS L1 Distance to nearest: Well oundation Property Line 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 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 callll for all required inspections. Complete drawing on reverse side. Signed X I�-�[it�ca��.- Title: _ Liv MLQ a- Date: r` OR DEPARTMENT USE ONLY jf Application Accepted by L"f Date ~~` Area f Pit or Grout Inspection by Date S Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca a23-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 K(� FEE \ INFOfAMOUNT�gDUjE AMOUNT REMITTED CASHRECEIVED BYDATE PERMIT'NO. EH 13-24iREV.IiAsl ilftt1�"`� �EH to-16