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I APPLICATION FOR PERMIT - l SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 IPER' MIT EXPIRES TYEAR 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. • f!l.z `` Job Address AA 41W Y ity Lot Size PM Owner's Name W ll`�-/A m M&DIE S Address S�Af E Phone. ./,F-�13 44s— Contractor 9,6 5; -&160-e b Address _7 A/ , License No. C'�?L Phone i-— 7 TYPE OF WELL/PUMP:,,,, _ NEW-WELL ❑ WELL REPLACEMENT.ZEI - — -DESTRUCTION 0- PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DIST_ANCE TO NEAREST: SEPTIC TANL SEWER LINES DISPOSAL FLD. PROP. LINE E i FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ I4LWIrial - ti„_ 0 Open.Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private D_G7ael Pack ❑ Tracy i Type of Casing Specifications M Public I7 Other rl-Delta , �� Depth of-Grout Seal �. Type of Grout .� I I Irrigation _..Approx. Depth � l I Eastern Surface Seal Installed by ',Repair Work Done ❑ Type of Pump. f H.P. State Work Done W611 Destruction ❑ Well Diameter Sealing Material (top 50') {' { Depth Filler Material (Below 501I TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION T DESTRUCTION 11 {No septic system permitted if public sewer is' i `9 ,available within 200 feet.) , InMallation will serve: Residence Commercial_ Other w Number of living units: -� _ `• " _L Number of be Character of soil to a depth 0 3 feet: f' f _ Water table depth ° SEPTIC,TANK " Q' Type/Mfg f� TE �`I"'9�'L Capacity f'ton= No. Compartments Z PKG. TREATMENT PLT. 0 t , „Method of Disposal Distance to nearest: Well IS0 Foundation /44 z A--Property Line', 7,S" LEACHING LINE No. & Length of lines 1 - 40 Total length/size FILTER BED ❑ Distance to nearest: Well Foundation 3d Property Line 7S� / 3 SEEPAGE PITS I Depth �'� Size Number SUMPS Cl Distance to nearest: Well Foundation -5-0 Property Line ZV1 DISPOSAL PONDS CJ 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, r f Home owner or licensed agent's signature certifies the following: ° g g g: "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 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 i Thea applicant must Cali for all required pp in q pection Complete drawing on reverse side. Signed• Title: FOR DEPARTMENT USE ONLY � / A plication Accepted by Date�%1.2— ,?�� Area Pi or Grout Inspection by Date / y'(L(L Final Inspection by�`� �9 Date/ � I Additional Comments: E ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Maritecs 823-7104 ❑ Tracy 835-6385 t Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AI4�ljOUNTDUE � � AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT"NO.09 P \ r ♦ EH 124{REV.t/n 57 ° �e �� iaj / v EH f4-4-2e V t