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APPLICATION FOR PERMIT 4 SAN JOAQUIN LOCAL HEALTH DISTRICT z 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 4f PERMIT EXPIRES TYEAR 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. 1662 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. I ' //��- • Job Address 19S13a NP }�LlL�, - City f"z�[rxf0 rte Lot Size �^ PM Owner's Name 16EL'14h IVA/,/, Address {L��D _ _ Phone / N (�F'$iTl (�4'11 P�S � _ ��L'y" 1 Phone Contractor Address 5 l �P_ License No. TYPE OF WELL/PUMP: NEW WELL 1. WELL REPLACEMENT DESTRUCTION ❑ # PUMP INSTALLATION V SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK 100, SEWER LINES AMS DISPOSAL FLD. PROP. LINE =a:fQ� FOUNDATION AGRICULTURE WELL khLZ_ OTHER WELL_, PITS/SUMPS j INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS i ❑ Industrial ❑ Open Bottom LI Manteca Dia. of Well Excavation 17 Dia. of Well Casing 104 tDomestic/Private Gravel Pack ❑ Tracy Type of Casing_ Specifications j f'l Public M.Other ll Delta Depth of Grout Seal /C�', , „..._ Type of Grout I I Irrigation _Approx. Depths , i I Eastern Surface Seal Installed by t.Lf_ Repair Work Done V Type of Pump cS _)_� H.P. I State Work Done _ �n 1 Well Destruction ❑ Well Diameter Sealing Material (top 501 v� Depth Filler Material {Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION i I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) f Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms Character of.soil to a depth of 3 feet. Water table depth [ SEPTt&xTSANK ❑ Type/Mfg Capacity. No. Compartments f PKG. TREATMENT PLT, ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines ` " Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I 1 Depth Size' _ Number ) SUMPS 0 Distance to nearest: Well Foundation Property Line r DISPOSAL PONDS ❑ i I hereby certify that 1 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 s ca I for all!r?ctuyed ins tons. Cor,I I t drawing on r verse side. 7 1 Signed X .�C/1'1�� Title: Date: C FOR DEPARTMENT USE ONLY Application Accepted by Date Area Pit or Grout Inspection by Date Final Final Inspection byeDate=a '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 L - INFO fEE AMOUNT DUE AMOUNT REMITTED CK C SH RECEIVED BY DATE PERMIT NO. +.EH13-24iREV.i/H51 ` 11 EH t4-2a