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APPLICATION.FOR PERMIT . SAN JOAQUIN LOCAL HEALTH DISTRICT I 1601 Er.`HAZE:TON AVE.,.STOCKTON, CA 1 Telephone (209).466-6781 ' PERMIT EXPIRES I YEAR FROM DATE ISSUED �' (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 orrNo. 1862 for well/pump and he Rules anA Regulations of the San Joaquin Local Health District. I,.+ �}�q n f 7 Z Job Address I1 7S VYi'f I; V l& t4s - l u _ _ City Lot Size 5 PM Owner's Name jrtl f�f)�.f ) Address �frlf`��.c rt!�1�— !� phone -7 t5 3czc'c�J T74-t Contractor !0- Address fa � _ !�•-�-_License No.��Phone r TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ W DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ r: DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHERFWELL PITS/SUMPS ( INTENDED USE TYPE OFiWELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ( 1 ❑ Industrial ❑ Open Bottom ❑ Mantec_a�� t'�'Dia�of Well Excavation r Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing ( l Specifications t ❑ Public ❑ Other ❑ Delta De th of Grout Seal I i ti - . P Type of Grout O Irrigation Approxi-Depth L2 Eastern Surface Seal Installed by I Repair Work Done Ll Type of Pump H,P, I i ° -� •'-�•� State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') i i 1 ` # k Depth rl - Filler Material (Below 50') I i I TYPE OF SEPTIC'WORK:. NEW INSTALLATION El REPAIR/ADDITI ON DESTRUCTION ED.-(Noseptic system permitted-if Ou lic sewer is 4 fs/ `available within 200 feet,l.E f '- t Installation will serve: Residence Commercial_ Other ~4 1 + Uk ' I Number of living units:_� Number of bedrooms !V — I I Character of soil to a depth of 3 feet:i�4L1e1C _ ! 1— _ _Water table depth ' SEPTIC TANK [��Type/Mf -Z-0 - e " 1 �� F r 9 Capacity�Z No. Compartments I PKG. TREATMENT PLT.17 4 _ r - r Method of Disposal Y "{ Distance;to nearest: Well cLRD Foundation 24f _ Property Line LEACHING LINE �' Ci� No. & Length of lines —.tdl Total length/size o 3 r FILTER BED D'*Distance tb n6 arest:f Well ihnn' Foundation�JProperty Line w 'k a y } t SEEPAGEPITS Ll Depth., Size :, ..� `^ .. wNumbe' l SUMPS ❑ Distance!to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ rt ,r 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'Distrlct. t Home owner or licensed agent's signature certifies the following: "I certify that in the performar ce of the work for which this permit is issued, I'shall not l employ any person in such manner as to become subject to workman's compensation laws of Califorr ia."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 ust call for all re vire I a s. Complete drawing on reverse side. Signed X Title: I I Date: e � # # FOR DEPARTMEN USE ONLY rF Application Accepted by D e d —G iy Area a 17 Pit or Grout Inspection by Date final.-Inspection by ; Date Additional Comments: 4 r, ❑ Stk 466-6781 ❑ Lodi.--369-3621. ,x_ ❑ Manteca 623-7104 . ..�0,Tracy--835-6385- - I _i Applicant - Return all copies to: Environmental Health Permit/Services 1601.E. Hazelton Ave., P.O. Box 2009, Stk., CA 95207. I I I FEE INFO AMOUNT DUE " AMOUNT REMITTED, C RECEIVED BY — DATE PERMIT NO { + EH 13-24(REV.1/s 5)' ��Gq11 t EH ia•26 1