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' APPLICATION FOR PERMIT N JOAQUIN LOCAL HEALTH DISTRIC 3 1601 E.. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1'YEAR FROM DATE ISSUED (Complete in Triplicate) Application is heie6y 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 Joaquini Local Health District. - Ave Job Address A - City �OC'�� Lo Size PM Owner's Name L A�QQrnass� _ q�� I� Phone 1-7 diens �� License No. Phone ��dnr•�5(R0 1 ocKr S/ - S I CTV 7S Contractor �Lp TYPE OF WELL/PUMP: NEW WELL D4 . WEL REPLACEMENT. ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ _ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK, - SEWER LINES - DISPOSAL FLO. - PROP. LINE I FOUNDATION AGRICULTURE WELL L OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL - PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial �b❑,rOpen Bottom ❑ Manteca - Dia. of Well Excavatio I /! Dia. of Well Casing ❑ Domestic/Private ><Gravel Pack ❑ Tracy. Type of Casing : �rr�- Specifications f`I Public - F.1 Other 1-1 Delta Depth of Grout Seal T pe of Grout I I Irrigation .Approx. Depth 1.1 Eastern Surface Seal Installled by Repair Work Done U Type of Pump.. H.P.- State Work Done _ Well Destruction ❑ Well Dia et r�. Sealing Material (top 50') Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is 1 available within 200 feet.) „ Installation will serve: Residence -Commercial_ Other Number of living units: _ Number of bedrooms - {1 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. 8 Length of lines J -Total length/size FILTER BED ❑ Distance to nearest: - Well .Foundation Property Line �. SEEPAGE PITS - I I Depth - Size - Number SUMPS ❑ Distance to nearest+ " Well Foundation 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 Di3trict. . 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 permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." I, The applicant ust call for al qve Icoons. Complete drawing on reverse side., I}[ Signed Y, Title;Title: SIIYL ��wG' Date: FOR DEPARTMENT USE ONLY Application Accepted.by - - Date Area Pit or Grout Inspection by - Date Final Inspection by Date Additional Comments: ❑ 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 FEEk INFO AMOUNT DUE AMOUNT REMITTED C SH RECEIVED BY DATE PERMIT NO. ..EH 13-24 I REV.It x 51 EH 162