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APPLICATION FOR PERMIT I SAN JOAQUIN LOCAL HEALTH DISTRICT a 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1-YEAR FROM DATE ISSUED I° (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. � � u Job Address Cit Lot Size X PM � Owner's Name Address '"} , r Phon5y -6 /4 av . r r � • Contrac Address • License No. ZZ-( Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ I __ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ (f; DISTANCE TQ NEAREST'SEP71C TANK'- SEWER-LII ES"�'"'"` =DtSPOSAL*FLD" —ZOP,-LINE- FOUNDATION AGRICULTUfik WELL } t* OTHER WELL PITS/SUMPS -INTENDED USE — TYPE OF WELL _PROBLEM AREA yCONSTRUCTION SPECIFICATIONS [I Industrial ❑ Open Bottom '❑ Manteca pia- of Weil Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel PackTracy Type of Casin j� YP 9 Specifications i"1 Public ❑ Other ❑ Delta Depth of Grout Seal I I Irrigation ' Type of Grout 9" —.-Approx. Depth I 1 Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump i State Work Done R Well Destruction ❑ Well Diameter ! Sealing.Matiial (top 50'I ii 9 Depth r � 1-, ` Below-50.'.) s __ 1J1✓! f .�_.F.iller..Material J Below-50'.l.�l TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION t I DESTRUCTION I I (No septic system permitted if public sewer is Ia- - - ---- -w.c -- -�---� �1 available within 200 feet-) 1' Uj Installation will serve: Residence_ ,Commercial_ Other- Number of living units: Number�of be ooms � Character of soil to a depth of 3 feet: SEPTIC TANKType/Mfg a Water table depth Capacity&— No- Compartments PKG. TREATMENT PLT. ❑ , r ,�+�, �� I Method of Disposal Distance to nearest: WeII Foundation; .property Line 37 00 LEACHING LINE ` No. & Length of lines i Total length%size. FILTER BED EDDistance to nearest: `lh/elI `Foundation Prope y Line SEEPAGE PITS Depth Y, 4 5iier w� L Number SUMPS CI /Distance to nearest: ,..Well L?D Foundation _ property Line DISPOSAL PONDS ❑f '` ,.,,, 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 Jbaquin�`Local�-Heaith-Di ir'ict� - 1 Home owner or licensed agent's signaturie 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 mariner 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 rc.Neall fo re fired inspections. Complete drawing on ravers si Signed X ary .r� ♦r . .�r y 1 ., ,w. Title: Date: ' FOR DEPARTMENT USE ONLY Application Accepted by Date rY Area w' Z Pit or Grout Inspection by bateFinal Inspection-16y- -� Date Additional Comments: �I ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 r Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 I FEE gMOUNT DUE AMOUNT REMITTED CK INFO CASH RECEIVED BY DATE PERMWNO. a.EH 13-24(REV.i i,t 5) .i EH 14-26 4'J i