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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA ' Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to the Sani 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 welUpump and the Rules and Regulations of the San Joaquin Local Health District. `A { I Job Address 0 �_ L � - y � City � Lot Size 4r PM Owner's Name �3�11tn 11ef1��_� Address V"I r Phone 1 C6 4LR IL Contractor Address License No. Phone 31 TYPE OF WELLIPUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑•• tPUMP INSTALLATION Els `' SYSTEM REPAIR.❑ OTHER-O. DISTANCE TO NE4REST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE 1 § FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS \ 1 " V t INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS i ❑ Industrial ❑ Open Bottom ❑ Manteca Dia- of Well Excavation- Dia. of Well Casing ❑ Domestic/Private LI Gravel Pack ❑ Tracy Type of Casing Specifications I-1 Public ❑ Other ❑ Delta Depth of Grout Seal`` n Type of Grout _ i I Irrigation _Approx.,Depth t I Eastern Surface Seal Installed by _ Repair Work Done ❑ Type of Pump H:P. $ -State Work Done Well Destruction ❑ Well Diameter Sealing Material Itop 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION UAIR/A (TIO I I ST UCTIQN It I-INo septic system permitted if public sewer is . available within 200 feet.l 'Installation will serve: Residence Commercial K Other ; r Number of living units: -__,.,I-.-._ Number of bedrooms Character of soil to a depth of 3 feet: Water table depth } SEPTIC TAMC ❑- Type/Mfg Capacity( No. Compartments PKG. TREATMENT PLT- ❑ Method of Disposal Distance to nearest: Well Foundation Property Line NO .° aI 1 LEACHING LINE ❑ No. & Length of,lines. -tea., b Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line s SEEPAGE PITS I ) Depth I. s ! Size 3-�ri -1dt-P, /5$_— Number IQ e- ea ¢�., �15% 3 3 SUMPS ❑ Distance to nearest: Well_ 01+ .Foundation Property Line Ifs DISPOSAL PONDS ❑ '_,' I J ' 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 Di§trict. f 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,Vshall employ persons subject to workman's compensa- tion laws of California." The applicant must call for all required i ctio Complete drawing on reverse-side. i Signed Title: r 0_Q Date: C3—24— b b -_ l FO DEPARTMENT USE ONLY Application ApCepted by v Date fly' Area ` �4� n rout Inspection by Date i5S' Final Inspection by v Date Addi ional abuts: 494 - ❑ Stk 466-6181 ❑ Lodi 369-3621 ❑ Manteca a23-1104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services,1601 E. Hazalton Ave., P.O. Box 2009, Stk., CA 96201 FEE AMOUNT DUE AMOUNT REMITTED C SH `,::RECEIVED BY DATE - PERMIT''NO. " INFO /} + EH 13-24(REV. i x 5) �r~ e ' �(/ Ao EH 14-28 I 4