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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6761 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. �l Job Address /V,22 Q Z> -Ae.M i( a Cityloo Lot Size AQP� PM Owner's Name �Q e-��Sp,v Address 91401e Phone Z 3 ♦//JJ Contractor tf Address License No. 0 57,2Z Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER O DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE E FOUNDATION AGRICULTURE WELL OTHER WELL - PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing e ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications F M Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout I I Irrigation —Approx. Depth 1 I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done_ Well Des1 truction EIWell Diameter Sealing Material (top 50.1 + Depth Fitter Material IBelow 50') TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION DESTRUCTION I I IND septic system permitted if public sewer is available within 2DD feet.) Installation will serve: Residence ✓ Commercial_ Other Number of living units: __L Number of drocros 2— Character of soil to a depth of 3 feet: Br La jyF Water table depth c SEPTIC TANK ❑ Type/Mfg --, Capacity No. Compartments rr PKG. TREATMENT PLT.❑ aUi Method of Disposal Distance to nearest: Well �. Foundation Property Line - 1 -f I 0 '�✓ LEACHING LINE fff No. 8 Length of lines fJ,x Total length/size 1 FILTER BED ❑ Distance to nearest: —,WellFoundationA 0 1 Property Lina. 60' SEEPAGE PITS UJ/Depth 2TSize 3 r {� 1 -XN�umber Z—_ �' SUMPS' LI Distance to neo ti—"Well d ion-L .� 1 Property Line e70M�, DISPOSAL PONDS ❑ / S\ hereby certify that I have prepared this application and that the woilk will be done in accordance with San Joaquin county ordinances, state laws, and, `C rube and regulations of-the San Joaquin Local Health 03trict: Home owner or licensed•agent's signature certifies the followin I certify that in the performs\e of the work for which this permit is issued, I shall not employ any person in such manner affc,become subjridt to. orkman's compensation laws of California,"Contractor's hiring or sub-contracting signature certifies,the following:"I certify that in the pertorm_ante-Uflij work for which t-ii paTmltis issued,A's al employ persons subject to workman's compensa tion laws of California." S� J� ` j � f The appGcanj�muyst Callforall r uired inspectionrr•-Gompteiedr3wing on reverse side. "� Signed X. / t•Title:(•/�.f1'/T Date: T FOR DEPARTMENT USE ONLY Application Accepted by Date Z Area Pit or Grout Inspection by Date Final Inspection by Delle 12,3d"tf I Additio[`�al Comments; ❑ Stk &�7Bt—�-B-L-odi—%59821----E7ldantece--823.7104---8^ha Applicant - Return all copies to: Environmental ieelth Permit/Services 4601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 1EEINFO ^'EAMOU/N�T DUE AMOUNT REMITTED /CASH RECEIVED By DATE 9 PERMIT NO. .,FH 1124 IREV.+final 7o-a0 � co `�� / �) /h�� O 00