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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 (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, J Job Addressi.3.7.('1 k/, City 94 %'� ' Lot Size PM Owner's Name U d I n a 1?C Address S A7?94?— C4-5 Joy—e__ Phone C1�s�q—.2� Contractor C Address <+' '7 /'!, ?� License No. �� 12•-Z Zi3 �. Phone TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ _ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ A. DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. k PROP. LIf- , FOUNDATION ° AGRICULTURE WELL `OTHER WELL ' PITS/SUMPS i INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ` j k. F i (9 ❑ Industrial ❑ Open Bottom Manteca Dia. of Well Excavation /f Dia. of Well Casing Private Gravel Pack ❑ Tracy Type of Casing Y `! r —�jc1�3Q Specifications C/ass'❑ Oth r Ci Delta Dpth of Grout ea' - T � ? �1 ''ff �-t � YPe at Grou��omestic/ � D Ifff iga//ionu r �-r pprdx. Depth I I Eastern Surface Seal Installed by /Rpafr 9Vark bone ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filter Material (Below 501 _ d TYPE OF SEPTIC WORK: NEW INSTALLATION Ia REPAIR/ADDITION I I DESTRUCTION i I (No septic system permitted if public sewer is available within 200 feet.I 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 Capacity No. Compartments PKG, TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size ro FILTER BED ❑ Distance to nearest: Well Foundation Property Line ' SEEPAGE PITS I I Depth Size Number 7' 1 SUMPS Ll Distance to nearest: Well' ' Foundation ' Property Line I DISPOSAL PONDS ❑ n 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 the following: "I certify that in the performance of the work for which this permit is issued, I shall notes-' 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." t h The applicant call f r all requirIns tions. Complete drawing on reverse side. N Signed X ` Q�� Titre: Date:`J AR DEPARTMENT USE ONLY t Application Accepted by Date ��`� C7 Area_- 3 Pit o ro Inspection by Date Final Inspectionby Date Additional Comments: 4�'�ra f� 4,y,sfi✓�� q✓�EO �f J�f!� �� !� c� fes/ dd � ❑ Stk 466-6781 ❑ Lodi 3691 ❑ Manteca 623-7104 ❑ Tracy Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazaltoh Ave., P.O. Box 2009, Stk., CA 95201� ,eZv6FEE JrC� INFO MOUNT DUE AMOUNT REMITTED ASH RECEIVED BY DATE /�PERMIT'�NO. +.EH 14-24 IR£Y.t i e sJ ,0� y , D /,/D l jt� EH 14-28 (� '"( ll! b -