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i� II APPLICATION FOR PERMIT 3 !1 SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA • - ' t°` ' j { , Telephone (209) 466-6781 c " `+J-,NQ� PERMIT EXPIRES 1 YEAR FROM DATE ISSUED II (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. 'II Job Address �1y ab I //eGL$�y,� r ��!.._� City Aefi±XenLot Size aze" PM w rI Owner's Name /ca/ . Address � phonep 22iv—44" 'I .I Contractor Address License foto, Phone ,;TYPE OF WELL/PUMP: , NEW WELL WELL REPLACEMENT D DESTRUCTION ❑ /Vp,5'��sfic �tC PUMP INSTALLATION SYSTEM REPAIR D OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE - FOUNDATION , _ AGRICULTURE WELL OTHER WELL PITS/SUMPS,,— INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 0 Industrial ❑ Op Bottom ❑ Manteca Dia. of Well Excavation_ " `F p 1�...._.— Dia. of Well Casing ❑ Domestic!Private Gravel Pack ❑ Tracy `e Type of Casing f�lJ C r� Specifications " C3 1-1 Public D Other Ll Delta Depth of Grout Seal �,F 51 Type of Grout [� iFV 171-1 It 1 v ! I Irrigation _.-Approx. Depth I I Eastern Surface'Seal Installed by S'a%1-P Repair-Work Done.-L] Type of Pump �3�� H.P. _ S� State Work Done_ Well Destruction ❑ Well Diameter Sealing Material (top 501 .` Depth F: Filler Material !Below 501 TYPE OF SEPTIC WORK; NEW INSTALLATION l 1 REPAIR/ADDITION l 1 DESTRUCTION I t Mo septic system permitted if public sewer is- I% r� F available within 200 feet.) Installation will serve: Residence �Commercial_ Other' Number of living units:'--- Il Number of bedroom's r 1'. Character of soil to a depth of 3 feet:., �� `,l"�`. � ,i� p Water table depth `SEPTIC TANK ❑ Type/Mfg Capacity f! No. Compartments PKG. TREATMENT PLT. ❑ II Method of Disposal ` Ih �. 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 I Depth f--Size'.' _ Number d, SUMPS U Distance to nearest: Well Foundation Property Line ,DISPOSAL PONDS D ' 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 c for all r quired ' pec 'ons. Complete drawing'on reverse side. Signed X �!� Title: ��(f�Lr�Ca� Date: A;,1 FOR_DEPARTMENT USE ONLY j .Application Accepted.by n, Date Pit or Grout Inspection by ;! Date Ficial Inspection by // 1 Date J Additional Comments: r ❑ Stk 466 6781 ❑ Lo !(369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-638 i Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 4 FEE INFO AMOUNT�DUE AMOUNT REMITTED Ck RECEIVED BY DATE PERMIT'NO. + EH 13-24 1 REV.t i x 51 EH 14-26