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APPLICATION FOR PERMIT . - 3vS� SAN JOAQUIN LOCAL HEALTH DISTRICT .. . ! - I 1601 E. HAZELTON AVE., STOCKTON, CA � ( f 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 Ryles and Regulations of the San Joaquin Local Health District. 19 p� Job Address :• r SL4 fit City Lot Size 3 , 6 -P3PI Owner's Name +� a� Address + �""' Phone ContracFor� Addressa - �1�i1Z1 6ei""" License No. ` Phone `'TYPE OF-WELL/PUMP:--- ------NEW WELL-9— WELL REPLACEMENT„❑ - . DESTRUCTION ❑ R� _ .. PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ , DISTANCE TO NEAREST:.SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE s '`FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS O'Industrial w 4--,* ❑ Open Bottom, ❑ Manteca Dia. of Well 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 H.P. State Work Done C'�a Well Destruction ❑ Well Diameter Sealing Material (top 501 I C•+; Depth Filler Material IBelow 501 TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is { available within 200 feet.) Installation will serve: Residence Commercial— Other Number of living units: umber of bedrooms Character of soil to a depth of 3 feet: t ` ` f Water table depth C ' SEPTIC TANK Type/Mfg �-• Capacity-- GO' o:'Compartments PKG. TREATMENT PLT. ❑ � Method of pis�av, Distance to nearest: Well ! 0 Foundation Proper III ty Line t ` LEACHING LINE No..& Length of lines' e. - Total length/size'- ”` t s FILTER BED ❑ Dist ce to nearest: Well'�..:��_Foundation /6 ;7� Property Line_ SEEPAGE PIT DepthSize U °N fnber',"? SUMPS ❑ Distance to nearest: Well/foundation /U 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. , Home owner or licensed agent's signature certifies the following: '$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." a r l The applicant must c for II requ' 'nspe ons omplete drawing on reverse ide. a `� Signed Title: Date: I FOR DEPART NT USE ONLY Application Accepted by Date Area w Pit or Grout Inspection by Date Final Inspection Data �" t Additional Comments: �+-UuhF OirTt,;�]� - ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6365 2- .4j ezf ed Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 616i'F,_0�� FEE AMOUNT DUE AMOUNT REMITTED ASH RECEIVED BY DATE PERMIT"NO- INFO + EH 1324fREV.ti/e57 - • EH 14-26