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F ' i APPLICATION FOR PERMIT i I SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 i PERMIT EXPIRES TYEAR FROM DATE ISSUED i (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a.pefmit 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. Job Address City 7-12A 5!f Lot Size &e y 2-7-C PM Owner's Name F)MAlk.._. Address z` Phone Z-43%_—.24077 N Contractor P46 V-0 AT. IJ60D Address Z �� APd04:aE4= .4440' License w.6�7 7--71- Phone 66-397 TYPE OF WELL/PUMP: NEW WELL ❑ _ WELL REPLACEMENT❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ 4 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE , FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout __ I Irrigation _.-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 .f Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION(]] REPAIR/ADDITION A DESTRUCTION I I (No septic system permitted if public sewer is ,�-- available within 200 feet.) Installation will serve: Residence Commercial_ Other �(} Number of living units: _L-__ Number of bedrooms -3 Character of soil to a depth of 3 feet: 411—A Water table depth SEPTIC TANK IJ Type/Mfg C X I 5 7-11 VLS Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance tD nearest: Well Foundation Property Line V LEACHING LINE ❑ No. & Length of lines Total length/size _qel? 3Z� FILTER BED JQ Distance to nearest: Well Foundation 4�9 r Property Line S SEEPAGE PITS I I Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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 I s rules and regulations of the San Joaquin Local Health District. I 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, I shall employ persons subject to workman's compensa- tion laws of California." l The applicant must call for all required inspections. Complete drawing on reverse side. Signed X Title: _ _ Date: FOR DEPARTMENT USE ONLY s Application Accepted by Dat 67 1 Area Pit or Grout Inspection by Date Final Inspection by Date y Additional Comments: Wd_rc.c_4 Cdtn,! .571&4� 1-4 Ft4eZ Z 4-4c4:F.-al,_� ❑ Stk 466-6781 ❑ Lodi 36921 ❑ Ma4teca 623-7104 O Trfcy 835-6386 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk.,' CA 95201 i FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT"NO. INFO +.EH13-24(REV.i/K5) EH 14-26 C) n C� 1)7