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I tr t APPLICATION FOR PERMIT r SAN JOAQUIN LOCAL�HEALTH DISTRICT i1} ' 1601 E. HAZELTON+AVE., STOCKTON, CA PAYMENT Telephone (209) 466.6781 RECEIVED PERMIT EXPIRES 7 YEAR'FROM•DATE ISSUED' (Complete in'Triplicatej OCT 31 �,. w } , ASO JOAQUIN COUNTY Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install t r 1 made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump an "eAU4 !cation is Local Health District, ► + r � �W t b=J M—oaquin Job Address Ci F L `L'ot Size PM Owner's Namf/1r>✓t. i AddressYl�3ltyppv.JJ�i�-� �t Phone d+�- Contractor C { e Address License No. Phvne —;f��J TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER O DISTANCE TO NEAREST:-SEPTIC TANK SEWER LINES-' DISPOSAL FLD `� PflOp.`LINE FOUNDATION AGRICULTURE WELL,L— OTHER WELL PITS/SUMPS _ INTENDED USE - TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing 111t Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications Cl Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout Ll Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done it Type of Pump., ( State Work Doff .� H.P, _ up Well Destruction El Well Diameter Sealing Material (top 50') '"1 j Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ElREPAIR/ADD(?ION 171' DESTRUCTION 11.(No septic'syst6m,permitted if public sewer is N `' ' '1•i atjaiiable;witfin 200 feet.) [/1 Installation will serve: Residence_ Commercial_ Other -, a Number of living units: Number of bedrooms Character of soil to a depth of 3 feet:SEPTIC om— SEPTIC TANK El Type/Mfg.f s A,`} K rf f Water table depth .{ Capacity L-...._— No. Compartments PKG. TREATMENT PLT. ❑ _ E " Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines 'Total length/size —4 *o FILTER BED ❑ Distance to nearest: Well �.. 1 Foundation Property Line I SEEPAGE PITS ""'❑.'"'.Depth"""..- -„-_,.,.-,.,-.;•Size'-"'"""`� '`..w.,...^ � -_-�.�� t : - Number ” ,^ SUMPS_ . .. * ,1 --- • ,� ❑=Distance-�to nearest.- 'Well ,_ � �,Foundation '-''tPro a DISPOSAL PONDS ❑ 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 1 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 all required inspections. Complete drawing on rse sl e. . t Sighed Title: Date: ' 1 FOR DEPARTMENT USE ONLY Application Accepted by a 95�� , * Date tv Q ��L " ' real Pit or Grout Inspection by Date Final Inspection by Dat-Akolffl Additional Comments: - ❑ Stk 466-6781 ❑ Lodi 369.3621 ❑ Manteca 823-7104 ❑ Tracy 835-6365 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 ` FEE AMOUNT DUE AMOUNT REMITTEDICU INFO r �77 CASH RECEIVED SY DATE PERMIT•NO. + EH 1324{REV,t/es) �3�/0 35 civ `747 l 0-3! ,- ] � EH]428 -1