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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. Telephone (209) 4.66-6781 „ r DATE fSSUED PERMIT EXPIRES I YEAR FROM DATE ISSUED (Complete in Triplicate) . . a ., Application is hereby made to the San Joaqul•n Local Health District for a permit to construct and/or install the work herein described. This application is node 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. Joh AddresszRacy SubdiVjsion Name Owner's Name MA je `hi &RA Kddress / F tea. Phone Contractor's Name License No.' 2 ty Phone 6 TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ', PUMP INSTALLATION INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCV TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATION5 „ Industrial ❑Open Bottom ❑Manteca Dia. of Well Excavation �❑ Domestic.=/Pri•vate----- ----M-Gravel- Pack-' Q Tracp - - w” ''-Dia.---of We114Easimgu T ❑ Public G Other E] Delta UirriType of Casing - ati n A rox. Eastern { g PP Specifications i CathodixProtection Depth ❑ Depth of Grout Seal ❑Geophysical ! ; # "'TOr of Grout �$x y ' I. F ❑other` 'a��, t Surface Seal Installed by Is IL ' Repair Wark'� one �] Lype of PiSmp Y H.P State Work pone I r r Well Destruc ion .j,Wel1�,Diameter_ 5_ealing Material-(,top--50")-W---"�--", eDepth' -ril ler Material (Below 50') TYPE OF SEPTIC WORK:} NEW INSTALLATION ❑ REPAIR/ADDITION )4 (No septic tank ar seepage pit permitted if pub c/sewer is T�`` available within 20 ;feet.) Installation will serve: Residence,. Commercial ; Other 1 # p, ; — ( Number of living units: Number of `bedrooms Lot size f ! Character of-soil to a depth of 3 feet: Q U is Water table depth ; f j SEPTIC TANK �fj Type/Mfg V-1-� _ Capacity No. Compartments Z I PKG. TREATMENT PLT. ❑ Type/Mfg _Capacity T Method of Disposes p„ SEWAGE SYSTEM 1 Distance to nearest: Well '---- Foundation _ Property Line r L DESTRUCTION LO ; * LEACHING LINEC) ! No. & Length of lines Total length/size r f FILTER BED f ! '� J -Distance-oto-nearest:*Y-Wel-1 /, Foundation s#,.2Property Line �--r; SEEPAGE PITS ❑ Depth Size 1 Number ' f SUMPSs v1T� Distance_to nearest: Well Foundation i Property Line DISPOSAL PONDS""❑ I hereby certify that I have prepared this application and that the work will be done in accordanceswith San Joaquin county i ordinances state laws,` and rules and regulations of the San Joaquin Lgcal.Health District. �.I Home ownerlor licensed agent's signature certifies the following: "I cert-ify that in the performance of the work for which this Permit is.issued,-Ii-shall not employ any person in such manner as to become subject to workman compensation laws of California." r,.�►, Contractor's hiring or;s ub-contracting signature certifies).the following:�,:'I certify that in the performance of.the work for which this permit is issued,U)'shi0'1 e_M_P oy persons 'subject to workman's compensation,laws of California." The applicant must ca114 t al equir inspections. Complete drawing on,reverse side. a Signed X i } .I Titlel: Date: G� FOR DFPARTMENT:USE„ONLY k { I Ap.pl ication Accepted by ❑( CJ�(1C� Area tf Stk 466-6781 �. 4 i Additional Comments: s ; L EJ Lodi 364-3621 Pit;or Grout Inspection by i Date , ❑ Manteca 823-7104 Final Inspection.Ny `T_ _-_( i� _ _ Da m ��Tracy 835-6385 Applicant Return all copies to: Environmental 4eAth Permit/Services 1601 E. Hazelton Ave., -P.0.jBox 2009, Stk., CA 95201 FEEM. .-' -BASE-- - AMOUNT�DUE:._ —AMOUNT.REMITTED �._...,.»....RECEIV.ED_BY__ Y INFO M 14-26 �^EH 13-24 � REV.0/8z- I