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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE i ON AVE., STOCKTON, CA Telephone (209) 466-6781 a PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) O'er ; '1 t_60 —1 'J 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 r 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. {^" /+'• h, ` � �ll�C��t Ci — I ty Lot Size (tom>�� - PM Job Address Owner's Name Address�a as-- • -[.frGc t my &0. �c.2c+.wftone 1 ' W 3� Contracto r Address� "8 �LicenseNo. z�ZY`�hone_ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ z PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ �. F DISTANCE TO NEAREST: SEPTIC TANK '.-SEWER LINESDISPOSAL FLD. PROP. LINE g , FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS W 'INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation ! — Dia.-of Well Casing ❑ Domestic/Private O Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal L' TypeF' Grout 1" C3 Irrigation ----Approx. Depth ❑ Eastern Surface Seal Installed by 'f6 Repair Work Done ❑ Type of Pump H.P. "_ - __State Work\Done?_ Well Destrucfion ❑ Well Diameter Sealing Material.(top 50') -r� x Depth Filler Material (Below 50') �.� TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ DESTRUCTION ❑ INo septic syetern permitted if public sewer is 1 t ( i available within 200 feet.) i Installation will serve: Residence_ Commercial Other :` a Number of living units: Number of e room — f i Character of soil to a depth of 3 feet: Water table depth s SEPTIC TANK gr'-T e/Mf Yp 9 z2 Capacity 12 0 No. Compartments �- PKG. TREATMENT PLT. ❑ ``� 7 Method of Disposal Distance to nearest: Well S L- Foundation 40 Property Line �r LEACHING LINE No. & Length of lines b Total length/sizee— 20 Ka FILTER BED ❑ Distance to nearest: Well - Foundation—/6 Property Line SEEPAGE PITS Depth Size sa�3. Number , SUMPS ❑ Distance to nearest: Well �-Foundation Q d DISPOSAL PONDS �- Property Line 171 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{iersons subject to workman's compensa- L tion laws of California." f. Thea applicant ust call for I required ins _ _ _ pp q inspections. Complete drawing,on reverse side._ Signed Title: r Date: _ FOR DEPARTMENT USE_ ONLY_ _ Application Accepted by - - -- M1 LL _ " Date j -T---6 Area • r Pit or Grout Inspection by_ Date--=— ---Final-Inspection by - Additional Comments: ❑ Stk 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 AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. + EH 13-24(REV.iiRs1 __7c,! �Q �Av EH 144.28