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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR'FROM DATE ISSUED _ Y ,� . .. (Complete in Triplicate) i,�, .3 :.: J. I Application is hereby 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 Ryles and Regulations of the San Joaquin Local Health District. . City Joh Address t F r " Lot Size D ��PM tea. d i A i Owner's Name .QAANA 9-n Address ` l 4V; 11LA.� V�1>'! �'"-' Phone D 11 Contra �4t1 AeAJ(2tdress License No. 0 Phone dR� TYPE OF WELL/PUMP: NEW WELL El WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ElSYSTEM REPAIR C] OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES { 'DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL I tOTHER 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 v ° ❑ Public ❑ Other ❑ Delta f Depth'of Grout Seal Type of Grout ❑ Irrigation ---Approx. Depth ❑ Eastern _ Surface Seal Instailed,by Repair Work Done ❑ Type of Pump T H.P. M State Work Done Well Destruction ❑ Well Diameter Sealing Material {top 501 { Depth IFiller Material,IBelow 50'1 r TYPE OF SEPTIC WORK: NEW INSTALLATION lE,� REPAIR/ADDITION ❑" 'DESTRUCTEON ❑ (No septic system permitted if public sewer is I . / available within 200 feet.) i Installation will serve: Residence Commercial 'Other _ ,J k Number of living units: __L_ Number o edrooms :%l 1 1 j Character of soil to a depth of 3 feet: Water table depth it SEPTIC TANK p�Type/Mfg +. a Capacity 0 No. Compartments r PKG. TREATMENT PLT. ❑ , rrl _ r r Method of Disposal { Distance to nearest: ,Wella Foundation—^I.0.- ._.-Property Line ..- LEACHING LINE 131,1"No. & Length of lines :3T Total length/size Q X r FILTER BED 1) Distance to nearest: / Well_� Foundation I D Property Line � i k SEEPAGE PITS 221"'Depth Size— Number SUMPS 11 Distance to nearest: Well. LTO Foundation_iAD .'Property Line_ DISPOSAL PONDS ❑ f' 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 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."Contractors Hiring or sub-contracting signature r 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." j The applicant m st call.fo a I requ�fired inspections. Complete drawing on reverse ide. 11 [t..f� l Signed `" Title: �{ Date: �^ FOR PARENT USE ONLY Application Accepted by _ _ Date- Area. it or Grout Inspection by ate Final Inspection Date2 Additional Comments: i ;- =� tV } JJJ ❑ Stk 466-6781 ❑ Lodi 369-3621 Manteca 823-7104 "❑ Tracy 835 6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CK CASH RECEIVED BY DATE {PERMIT"NO. + EH 13241REV.1i85Y q57 EH W26