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APPLICATION FOR PERMIT x; SAN JOAQUIN LOCAL HEALTH DISTRICT s 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 'I YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made.to the San'Joaquin Local Health District for a perry itto construct and/or installthework 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. Ll �7 ` `- Job Address- 2.l4 ! _k, 1\N-0 City Lot Size'' PM t Owner's Name , S. OCL t' t Address b� �!\ ouj Phone 4 Contractor's Name, rl x S Cos 1 License-N Phone TYPE OF WELL/-RUMP: -- �,._NFW WELL- WELL REPLACEMENT ,DESTRUCTIONmD— PUMP INSTALLATION ❑ OTHER ❑ DISTANCE TO NEAREST: SEP TANK SEINER LINES i DISPOSAL,FLD. PROP:LINE'S FOUNDATION AGRICULTURE WELL OTHER WELL I PITS/SUMPS ' y INTENDED USE TYPE OF WELL PROBLEM AREA) CONSTRUCTION SPECIFICATIONS f t I k ❑ Industrial ❑ Open Bottom / r Manteca Dia. of Well Excavation " Dia. of Well Casing I` Domestic/Private Gravel Pack ❑ Tracy Type of Casing ��f Specifications ; ❑ Public j ❑ Other ❑ Delta Depth of Grout Seal, _ J�� Type of Grout e_ 1 ❑ Irrigation _�_Approx. Depth ❑ Eastern Surface Seal Installed:by 1 Repair Work Done ❑ Type of Pump —H.P. State Work Done S3 Well Destruction ❑ Well Diameter Sealing Material (top 50') i Depth Filler Material 'f Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑-(No septic system permitted if public sewer is ' available within 200 feet.) Installation will serve: Residence_ Commercial_ Other Number of living units; s Number of bedrooms t Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity- - No. Compartments PKG, TREATMENT PLT. ❑ `'� Method of Disposal - Distance to nearest: Well Foundation Property Line 9 LEACHING•LINE—❑—No.'& Ler gth of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation ! j Property Line SEEPAGE PITS ` ' �❑ Depth i Size Number T SUMPS ❑• .:.Distance to nearest: Well Foundation s Property Line ,j DISPOSAL-PONDS O 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 j 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." 'sl The applicant libust call•fo_r,all required inspections. Complete drawing on reverse side. (� Signed X t'C� �'�t1� Ci5— OS -- Title: Date: '1 13 -24 I R DEPARTMENT USE ONLY Application Accepted by Date) 3 Area Pit or Grout Inspection by e �— ate- '°` M — Final lspection lb _ t Date� ° Additional Comments: � - °°" � � 7kcno Ve_ / l 2. 40- ❑ Stk 466-6781 ❑ Lodi 369-3621A ❑ Manteca 823-7104 ❑ Tracy 835-63851 -� Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O' Box 2009, Stk:, CA 95201 :N FEE INFO AMOUNT DUE AMOUNT REMITTED C K# f RECEIVED BY DATE PERMIT"N0. +EH 1324[REV.10!831 �_ � EH 14-26 1 O C? 1 ZQ�-� ti:J� ` %li-41 c