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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 TYEAR-FROM DATE ISSUED (Complete in Triplicate)- 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 Rules and Regulations of the San Joaquin Local Health District. Job Address qZ 3 S Fres AID City CLot Size PM +�� t x Owner's Name V1 C If&7 a- /_ l T Cdlarll Address ��/ �� ✓� Phone I�� ' 2 v",6 S-e1 -!� SaC«e,� Ira- Sg-Z.3- Contractor Address License No. Phone TYPE OF WELL/PUMP: NQ NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ _- =DESTANCEO.:NEAREST:_SEP-TIC_TANK.�._- SEINER��15-�_ pISP_pSAL_FLD. PROP. LINE x Y . 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 i=l Public F Other Cl Delta Depth of Grout Seal Type of Grout t-1 Irrigation -App(ox. Depth I ) Eastern Surface Seal Installed by _ Repair Work Done E Type of Pump H,P. State Work Done Well Destruction ❑ Well Diameters Sealing Material (to_p 50'1 - __? Depth t=iller Material.(Below 501 TYPE OF SEPTIC WORK: W INSTALLATION I� REPAIR/ADDITION I I DESTRUCTION {No septic system permitted if public sewer is �— available within 200 feet.) t Installation will serve: Residence' Commercial Other Number of living units: :Number.of bedrooms Character of soil to a depth of 3-feet + Water table depth SEPTIC TANK ❑ Type/Mfg r Capacity No'�Compartments PKG. TREATMENT PLT. ❑ Method of Disposal C Distance to nearest: Well Foundation Property Line a i LEACHING LINE ❑ 'No. &Length of lines Total length/size FILTER BED ❑ Dikance to nearest: Well . Foundation Property Line t a f SEEPAGE PITS t I Depth. Size_ Number SUMPS 0 Distance to nearest: Welt Foundation 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 Orstrict. 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 parmit is issued, I shall employ persons subject to workman's compensa- tion laws of California." b ` I The ap�plica t must call for al equired inspections. C�plete drawing on reverse side. Signed X -11., (� �'� "� Title: 1�' ! — Y' _— Date:,, ..- FOR PARTMENT US_E ONLY Application Accepted by _ \ Date -„_ Area Pit or Grout Inspection by _= :_ Date Final Inspection by U li av Date J`.)T-i' Additional Comments: r` ❑ Silk 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 RECEIVED BY DATE I PERMIT NO. ♦.EH13-24 TREY.1iR51 /may f £H 14-28J � - /9fy ,%, 1 61