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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT " 1601 E. HAZE l ON AVE., STOCKTON, CA ` Telephone (209) 466-6781 U PERMIT EXPIRES 1 YEAR FROM DATE ISSUED nil I (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 1s 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. .. / c ` _ Job Address / � �Jy � � < lC.. l �i'YL/ LC- � City L� Lot Size PM Owner's Name�� ` �-c-L'J �Z Address A0, X" f4-'Z Phone a 1 Contract .t Address r•�. L�L-A License No. 7 z G Phone A>> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION O PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER O DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. _ PROP. LINE FOUNDATION _ AGRICULTURE WELL OTHER WELL PITS/SUMPS r INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS C1 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing [1 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ('I Public ❑ Other - ❑ Delta Depth of Grout Seal Type of Grout �. i I Irrigation _Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done [] Type of Pump H.P. _ State Work Done _ Well Destruction ❑ Well Diameter Sealing Material (top 501 ,.. Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION X fit PAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is 9 available within 200 feet.) N Installation will serve: Residence _ Commercial_ Other O Number of living units: �_ Number of be r oms / Character of soil to a depth of 3 feet: -L Water table depth /t/�'``^' 7. _- SEPTIC TANK � Type/Mfg L C Z ZLe..1 Capacity �C No. Compartments PKG. TREATMENT PLT. ❑ / i Method of Disposal Distance to nearest: Well SLS Foundation_1y Property Line r LEACHING LINE No. & Length of lines _3 — YL/) Total length/size 62,� )(� r r i - FILTER BED ❑ Distance to nearest: Well Foundation_�� Property Line SEEPAGE PITS Depth Size Number_ r - r SUMPS LI Distance to nearest: Well ��_ Foundation / Property Line DISPOSAL PONDS C] I hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, arid 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 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." The applicant mini call for qui d inspections. Complete drawing on revorfe�rsido. /� Q Signed X \ ,L c� -- _ Title: J=---- _ Date: l C� ", /J lV C FORpEPARTMENT USE ONLY 11 (� r Application Accepted by " 1 /%� /�I / A�// Date / /�'f >_S l'�, Area Pit Grout Inspection by f✓, � r Final Inspection by t Date /� Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 O 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 �� r. FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT N0. INFO CASH r ♦ EH 13-24(REV.11 H 51 EH 14.26