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f 11 APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE r ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1'YEAR'FROM DATE 1SSUE'D (Coirlplete Jn Triplicate) " '•"""' '"'•a ' "� 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 H 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 Loco! Health District. � ., ,. , � el, et Job Address y•w ' 9,A r r r �]4 C1ty+ TLot Size 7�x S�C�r PM Owner's Name -l-�r A � � 7-1 h _Address �� C /I� phone I Contractor TYPE ,t �� Address X License No �T " P WELL/PUMP: ,a NEW WELL ❑ --�—�1.z hone r� WELL REPLACEMENT ❑ DESTRUCTION-❑„_ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ . DISTANCE TO NEAREST: SEPTIC TANK OTHER ❑ SEWER LINES DISPOSAL FLD, PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL INTENDED USEPITS/SUMPS TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS r ❑ industrial ❑ Open Bottom ❑ Man teca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing ❑ Public ❑ Other ❑ Delta Specifications l t t Depth of Grout Seal Type of Grout L3 Irrigation --Approx. Depth, " ❑Eastern - �j .� Surface Seal Installed by Repair Work Done ❑ Type of Pump A¢ 4 H.P.z.'- State Work Done Well Destruction ❑ Well Diameter Sealing Material,(top 501) Depth Filler Material (Below 501) TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ t REPAIR/ADDITION DESTRUCTION (No septic system permitted if public sewer is I Installation will serve: Residence_Commercial -_,. _available within 200 feet.} l. Other Number of living units: .Nuhiber of bedrooms Character of soil to a depth of 3 feet: SEPTIC TANK r Y,Water table depth ❑ Type/Mfg �;Q Capacity / QA No.,Compartments � PKG. TREATMENT PLT. ❑ tt - r Method of Disposal Distance to nearest: Well_ _ O, Foundation �� Pro f #;-�� I Percy Line� * LEACHING LINE No.,& Length of lines -�( D FILTER BED j 1 7' t: Total length/size #' �❑ Distance to nearest: Well Foundation _ I! Property line SEEPAGE:PITS ❑ Depth---------------Size-�-L-------_._ Number SUMPS ❑ Distahce to nearest: Well Foundation DISPOSAL PONDS ❑ Property Line 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�\�1 rules and regulations of the San Joquin Local Health District. Home owner or licensed agent's signature certifies the followin ' employ any person in such manner as to become subject to workman's compensation laws oof Califonce miahe Contractor's work forih ringch s or sub-contracting signas permit is issued, I tnot ure 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." i The applicant must call for all require inspections. Complete drawing on reverse side. Signed 4 Title: I T'I Date: Z � Ill FORD TMENT USE O L"Yr Application Accepted by rl' ( _ A. Date- : J -� A Pit or Grout Inspection by '! Date Final Ins ection by Date Additional Comments: 11 ❑ 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 AMOUNT DUE AMOUNT REMITTED CK# INFO CASH RECEIVED BY -DATE PERMIT N0. } EH W28EH 13-24 1REv.i/a5l SO (#1 - -3--Z