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�r4 , APPLICATION FOR PERMIT 3 SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA' - Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE.JSSUED (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 fol well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address city - 'I�Lot Size m I� QPM;. dress Owner's Nam S-0Phone ! e.i►., �L-icens,N4 - `S— !a ry S Phone -7Contractor's Name T TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ j SYSTEM REPAIR ❑ OTHER 71 ; DISTANCE TO NEAREST: SEPTIC TANK SEWER-LINES.,, DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL ' OTHER WELL PITS/SUMPS 3 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 1 ❑ Industrial ❑ Open Bottom ❑ Manteca Dia."of Well'.Excavation� Dia. of Well Casing` ❑ Domestic/Private ❑ Gravel Pack —❑ Tracy Type asing Specifications, i i ❑ Public ❑ Other ❑ Delta, Depth of Grout Seal Type of Grout ' Y ❑ Irrigation ---Approx. Depth ❑ Eastern h }Surface Seal Installed by s Repair Work Done ❑ Type of Pump HA S # State Work Done Well Destruction ❑ Well Diameter Sealing Material {top 50'1, vs4 1 Depth �.� Filler-Material•(Below 501` TYPE OF SEPTIC WORK: NEW INSTALLATIO REPAIR/ADDITION ❑ DESTRUCTION ❑ INo septic system permitted if public sewer is F available within 200 feet.) s Installation will serve: Residence_ Commercial Other Number of living units: Number of bedrooms c� `" I—," Water table depth Character of soil to a depth,of 3 feet:, """"`' I SEPTIC TANK ISI Type/Mfg � No. Compartments i I PKG. TREATMENT PLT. ❑ ' A'1- ' Method of�lDissp-o-se�l r � Distance to nearest: el F ndabon Property Line ,f LEACHING LINE .CI No. & Length of lines - Total length/size 1 � FILTER BED ❑ Distance to nearest: Well Foundation Q8'1t Property Line i SEEPAGE PITS Depth SSize i N�rrtiber SUMPS ❑ Distance to nearest:.'Well t Foundation "� Property Line DISPOSAL PONDS I hereby certify that I have prepared this application and that the work will be do a in accordance with Sa Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. Home owner or licensed agents'signature certifies the following: "I'certify that in the performance of the work for which this permit is issued, I shall not, F 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." y The appli nt m call fo uired inspections. Complete drawirig on reverse side., Signedg�"�r Title: c l Date: f ' FOR DEPARTMENT USE ONLY Application Accepted b Date Area o2L PP p Y . . 1 Pit or Grout Inspection by }ate Final Inspection by Date Zi F Additional Comments: ��X_tA_ -11 73 ElStk 466-6781 L1 Lodi 369-3621 ❑ Manteca 823-7104''` ❑ Tracy ' Applicant- Return all copies to: Environmental Health Permit/Services 1601 E: Hazelton Ave., P.O. Box 20.09, Stk.,,CA 95201 l FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT INFO + EH]3241REV.SOlB;i) - EH 14.26