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!1 APPLICATION FOR PERMIT ►. SAN JOAQUIN LOCAL HEALTH DISTRICT r 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ' (Complete in Triplicate) Application is heieby 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 well/pump and the Rules and Regulations of the San Joaquin I Local Health District. Job Address _� �� _.- City ' Lot SizePM 01 1 Owner'S Name.V 5 Q �,ct . �License NoPhone r rdrr, �i,�1A LKLT 1+A LL✓C Address _ TYPE OF WELL/PUMP: NEW WELL- WELL REPLACEMENT ❑ DESTRUCTION 5 PUMP INSTALLATION SYSTEMA REP IR ❑ OTHER 0 l DISTANCE TO NEAREST: SEPTIC TANK 20 SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL.3z PITS/SUMPS Z�✓ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial © Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casi g OG' .Domestic/Private Gravel Pack ❑ Tracy Type of Casing 45UC- Specifications�f�5,�Zo 1"1 Public fr f 1 Other F1 Delta Depth of Grout Seal Type of Grout 22 e�rJ I I Irrigation 2(Z.Approx_De th l I Eastern 4 Sura a Seal Installed by - - Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Z Sealing Material {top 501 6ZC�� �! + Depth Filler Material (Below 50 TYPE OF SEPTIC WORK: NEW INSTALLATION Ia REPAIR/ADDITION LI DESTRUCTION I I (No septic system permitted if public sewer is I available within 200 feet.I { Installation will serve. Residence_ Commercial_ Other Number of living units: Number of bedrooms Q Character of soil to a depth of 3 feet: Water table depth k SEPTIC TANK L] Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal �l Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines- E Total length/size I FILTER BED ❑ Distance to nearest:f- Well Foundation Property Line SEEPAGE PITS i I Depth Size Number SUMP'S CI Distance to nearest: s 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 rules and regulations of the San Joaquin Local Health District. Homeowner 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." The applicant njust call r al required i pections. Complete drawing on reverse side. ` I Signed X ti Title: PDate: OR DEPARTMENT USE ONLY is Application Accepted by Date Pit orlGrout Inspection by Date Final Inspection by Date11—J6�89 p Additional Comments: ❑ Stk .466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Appllcant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 11 IFEE NFO AMOUNT DUE AMOUNT REMITTED K RECEIVED BY DATE PERMIT'NO. �' .' , 1 rias•�� ) ) 7 � b�4 + EH 13-21(REV: EH 11-26 l