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r. APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT I 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR 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 _ I 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:+;f€a;. Job Address ^' '' � cityffQZ4±nALot Size PM 1 Owner's Name ress 4' ` Phone Contractor dress ` License Na1JUka Pflane /4 I TYPE OF WELL/PUMP; NEW WELL ❑ a WELL REPLACEMENT'El DESTRUCTION ❑ PUMP.INSTALLATION ❑ SYSTEM REPAIR Ea_ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK"% � SEWER LINES DISPOSAL'FLD. PROP. LINE FOUNDATION AGRICULTURE WELL 3 OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca `Dia. of Welt'Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack, ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump W.P. AE State Work Done Well Destruction ❑ Well Diameters ;N Sealing Material {top 501 Depth t "'`' Filler Material {Below 501 TYPE OF SEPTIC WORK: NEW,INSTALLATION-❑ REPAIR/,ADDITION C7—DESTRUCTION C1 (No septic system permitted if public sewer is I• '� f } —"' available within 200 feet.) ))) Installation will serve: .Residence F! Commercial Other Number of living units: Number of bedra'ms z ^° Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacityo�&2 - No. Compartments PKG. TREATMENT PLT. D ` y µ " Method of D-sposal s" Distance lo;nearest: Well'A947 Foundation_10 Property Line LEACHING LINENo. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well /OD b Foundation—e1 19 Property Line ~ SEEPAGE PITS ❑ Depth /.0 Al-7-Size Number U 5 } Distance to nearest: WellJ Foundation-f-1 _ Property Line_ DISPOSAL PONDS I 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 agent's signature certifies thefollowing:"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 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 Must SAI for all requ' inspections. Com late drawing on,re rse side. { Sig+neo X �!////^ �( Title: +r .f—�7��, r� Date: `' V FOR DEPARTMENT USE ONLY 4 Application Accepted by Date Area r Pit or Grout Inspection by Date Final Inspection by Date f r Additional Comments: +. ❑ Stk 466-Ml ❑ 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 CK 0 FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'N0. INFO + EH 13.241REV.1/85) EH 14-28 I C]• C�?C] ��