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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466_$781 PERMIT EXPIRES 1 YEAR FROM-DATE ISSUED . [Ai}G-�' t � (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the�herelndescribed. This application is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and th gulations of the San Joaquin Local Health District. "� Job Address r, C)tyLot Size 7, 74 CIZ£ PM a' Owner's NameAddressf [� .= - -�- - Phone" ' Contractor TA MIN q,J �,�5 Address ckiv.., S2 TYPE OF WELL/PUMP: NEW—WELL El WELL No. Phone'9(c!o'- 60 WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR Z OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK ° SEWER LINES DISPOSAL FLD. PROP, LINE FOUNDATION ,AGRICULTURE WELL BOTER' WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS L1 Industrial ❑ Open Bottom 19 Manteca, Dia. of Well Excavation ® Domestic/Private El Gravel Pack EJTracyof Tracy ' T Casin r a'- Dia. of Well Casing .''� g r�,Specifications ❑ Public ❑ Other ❑ Delta ,: Depth of Grout Seal EJ Irrigation —meq TYPe of•Grout f ---Approx. Depth ❑ Eastern t Surface Seal Installed by Repair Work Done`,.C7 Type of Pump H.P. State Work Done Well Destruction'. ❑- iWeli 6ameter Sealing Material (top 50') i Depth Filler Material (Below 50'► TYPE OF SEPTIC WORK: NEW INSTALLATION❑ REPAIR/ADDITION ®,,DESTRUCTION ID (No septic system permitted if public sewer is: i available within 200 feet.)! 4 lnstallation Will serve: Residence Corti ercial Other 4 Number of living units: '"Number of bedrooms Character of sail to a depth of 3 feet:�i�S.�?ND Y�[ j�y Water table depth r20 SEPTIC TANK ❑ Type/Mfg Cn TL Ca act /Zop ! i 6 p n'- No. Compartnrents PKG. TREATMENT PLT, ❑ -' -�- "-t�-�'� •- � e ': x Method of Disposal____L,---- - . Distance to nearest: Well n ao y^ Foundation 4d Property Line LEACHING LINE Q No'}& Length of iines } i Total length/size FILTER BED Distance to nearest: well Foundation property Line SEEPAGE PITS Q Depth Size 4 Number SUMPS ' Distance to nearest We II t Foundation DISPOSAL PONDS ❑ _ Property Line 1 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 ager;t'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." k The applicant must call for all required Inspections'. Complete drawing on reverse side- Signed Title: - Date: Z49:2?-,64 FOR DEP RTME ONLY Application Accepted by ��"f L � JJ ENT U5Date — Area Pit or Grout Inspection by i'V Date Final Inspection by. Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369.3621 Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental H a th Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED INFO CASHERECEIVED BY DATE PERMIT NO. + EH 13.24(REV.Lias) EH 10.26-