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APPLICATION FOR PERMIT -. �a 11 SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E, HAZEL T ON-AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM -DATE ISSUED:1 ' s. (Cometeplin Triplicate) y. "' ' r Application is hereby made to the San Joaquin Local Health District for a permit to construct and/ or install the wok 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 Ryles and Regulations of the San.Joaquin -Local Health District. 41. , .: Job Address of Cyy lc,7 t� y Size �--~" PM Owner's Name Address _�v lv c� j/i'ln�7l� -Phone - Contractor— t ZA /7_(J�Address License No., Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE � FOUNDATION AGRICULTURE WELL OTHER WELL PETS/SUMPS r INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation ❑ Domestic/Private E3 Gravel Pack Pia. of Well Casing ❑ Tracy Type of Casing Specification's ❑ Public ❑ Other E] Delta Depth of Grout Seal )Q>❑ Irrigation � Type of Grout L-1-Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Weli Diameter Sealing Material (top 501) Depth '"�'� Pilfer Material (Below 501) TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION DESTRUCTION ❑ (No septic system permitted if public sewer is (" available within 200 feet.) Installation will serve: Residence ��Commercial�t Other Number of living units:. Number of bedrooms , `, Character of soil to a depth of 3 feet: , ° SEPTIC TANKElType/Mfg �,� f- Water table depth PKG. TREATMENT CapacitNo. Compartments ALT. F1 � u` zg y �� Method of Disposal Distance to nearest: Well Foundation _ Property Line LEACHING LIN) ` IVo &:L'e_ngtFi of'lirie s�* Y�: 1000 -.- - r Total-length/size FILTER BED ❑ Diiiance to nearest:_' Well^ iFoundation F� ,. ,Property Line-z!M SEEPAGE PITS ❑ Depth Number DISPOSAL PONDS ❑ '-' SUMPS 11 ;Distance to-nearest-1.`.Well z v �� Foundation Property Line � Vti a%`? ,i I hereby certify that I•have prepared this application and that the work will'be dbr e-in accordance wifli San Joaquin county ordinances, state Paws, and rules and regulations of the San Joaquin Local Health District. I 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 4 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 call for yallefired " p'.21 . Complete-drawing on reverse side. 1 . Signed)�_" t �,-mss. L._ Title: ,Date: FOR DEPARTMENT USE ONLY Application Accepted by4 Date Area Pit or Grout Inspection by _ Date Final Inspection by " Date 1 Additional Comments: y C1 Stk 466-6781 1-1Lodi 369-3621 anteca 823 7104 ❑ Tracy 835 6385 Applicant- Return all copies to: Environmental ea h Permit/services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 INFOFEE AMOUNT DUE AMOUNT`REMIT EC71� CK# --pE6ElVED-BY . — ..._ —�; _ r " �16ASH A. ...._. „,DATEs '...:r PERMIT`NO. ..-. ..,, EH 1124 iFiff.-)ie5i EH 14-28