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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT ' ~ 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR ROM DATE ISSUED (Complete in Iriplicatei 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 welllpump and the Rules and Regulations of the San Joaquin Local Health District. Job Address 9'f. 7,DO "A1D W 6 L 4 13d, City 7A0 y l rola Lot Size PM Owner's Name ♦ 111441 G2''dff �6d rS Address ao /PI�wGG Rai Phone TY I �A/✓r/SP/Y 'S�� Address 6��► l3LvB vl�fi�UP. License IVo. �YY�/ Phone S;?3•- Contractor ' I TYPE OF WELL/PUMP: �. NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. POOP. LINE �__,,__ _.�..�,.-....:.--FOUNDATION AGRICULTURE.WELL OTHER WELL PITS/SUMPS r INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑.,,Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Ll❑',60mesti6Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications � (=1 Other i 1 Delta Depth of Grout Seal Type of Grout#[1'l Public •� _ ' I Orrigation w _Approx. Depth � i I Eastern Surface Seal Installed by - Repair Work Done ❑ Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material (top 501 '• �� • : `Depth �' Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION I1 REPAIR/ADDITION DESTRUCTION [ I (No septic system permitted if public sewer is F. availa� ble within_200 feet.) ' Installation will serve: Residence .. Commercial Other ' i Number of living units: Number ofT. bedrooms of Charactec.of soil to a depth'of 3 feet•. .4 !�f /.pi9�9 i k Water table depth_ /3 F. SEPTIC TANK,�,_ ❑" Type/Mfg Capacity ' No. Compartments n PKG. TREATMENT PLT. ❑I� INMethod of Disposal Distance to nearest: Well Foundation • ; '' :Property"Line•----------µIN0 ttt t �( LEACHING LINE, Re No. & Length of lines � l' Total length/size 8007 FILTER BED ❑ Distance to nearest: Well /00 Foundation !� Property Line f SEEPAGE PITS C I Depth Size" Number SUMPS Ll Distance to nearest: Well Foundation t- Property Line DISPOSAL PONDS ❑ a " 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 certifies the following: "I certify that in the performance of the work for which this permit is issued,l shall employ persons subject to workman's compensa- tion laws of California." The applicant must call for all required inspections. Complete drawing on reverse side: �k r t 4:t � p l-a Signed X ! - Title: Date: FOR DEPARTMENT USE ONLY Application Accepted by r- Date ^r� Area / 2- Pit or Grout Inspection.by Date Final Inspection by Date 5 - f t t i Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy B35-63$5 Applicant - Return all copies to.-.Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O.'Box 2009, Silk., CA 95201 i FEE AMOUNT DUE AMOUNT REMITTED CK - `RECEIVED BY DATE PERMIT'NO. INFO CASH• z r EH 13-24IHEv.1/n5l EH 14.26 ."