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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone f209) 466-6781 PERMIT EXPIRES TYEAR FROM DATE ISSUED (Complete in Triplicate) Application is heleby 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. �j f �r f EJobddress 3v3rt P6 ` Cit rC Lot Size / '�• PM r's Name FL5/E / _JSA �� Address L�63 !Y- 1! � � �pti Phone acl4r, L-Sr Address �f fl ke Ce^t License No. Phone TYPE OF WELL/PUMP: NEW WE WELL REPLACEMENT ❑ DESTRUCTION ❑ -PUMP INSTALLAT SYSIFEM REPAIR ❑ THER 171DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES _ DISPOSAL FLD. lPROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS �- INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS, ,►+ ❑ Industrial ❑ Open Botfom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing (� r Domestic/Private Gravel Pack El Tracy Type of Casing Specifications V) 1-1 `Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout--- i rout I I Irrigation I _Approxi Depth. l l Eastern Surface Seal Installed by _ Repair Work Done ❑ Type of Purnp _ H.P. �/ Z H-F7 State Work Done_ Well Destruction ❑ Well Diameter ��2.6f"_.._— Sealing Material(top 501 Depth Filler Material 1Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION i I REPAIR/ADDITION 1 I DESTRUCTION I i (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence I Commercial Other Number of living-units: Number of bedrooms 1 Character of soil to a depth of 3 feet Water table depth SEPTIC TANK `❑ .'Type/Mfg I Capacty'..^ No. Compartments PKG. TREATMENTyf'LT. ❑ or ""'-- Method of Disposal Distance to nearest: Well` ^` Foundation Property.Line LEACHING LINE ❑ No. & Length of limes Total length/size FILTER BED ❑ Distance to nearest: -:l Well" 't Foundation Property Line SEEPAGE PITS I IDepth ) -Size _ Number SUMPS ❑ Distancevlo nearest: r`Well ? Foundation Property Line 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 Diltrict. 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." Contractors 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." 5�u } T he applicant ustcall forall re fired inspections. Complete drawing on re¢v�jerse side.igned X �" Title: _(f/ 1�77��r✓ Date: FOR DEPARTMENT USE ONLY Application Accepted by 4, Date z Pit or Grout Inspection by Date { "k Final Inspection=by Date Additional Comments:S.— =1 r-&,A ..-.�c�r.�.�_ yz�n��y �a >V1 u- ❑ Stk 466.6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED ASH RECEIVED By ATE PERMIT'NO. ..EH13-24(REV.1/H5) EH 14-28 {