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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT • 1601 E. HAZEL t ON AVE., STOCKTON, CA 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 Rules and Regulations of the Sen Joaquin Local Health District. / r 1 �j 7,, J�,,� _ Lf nn LCb City C Lot Sirs�/0CY�.,Q�i PM Job Address rJ-� �] �.,t/'t ///{ 7 Owner's Name �A1 t�IYl` L�, Address 2u'6 ` b '"' ��"r Y�' `"r' 0 it Phone k Contractor Address License No. Pho TYPE OF WELL/PUM NEW WELL - .\ WELL REPLACEMENT 13t. DESTRUCTION ❑ . r PUMP INSTALLATION C3SYSTEM REPAIR ❑s OTHER`O DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES' DISPOSAL,FLO.- PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL r - PITS/SUMP$ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑Industrial ❑ Open Bonom ❑ Mentes`� Die. 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 ❑ Easter Surface SeaInstalled by ne i Repair Work Do ❑ Type of Pump _ H.P. Stat Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 I Depth Filler Material (Below 50') • TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ DESTRUCTION O Mo septic system Permitted If public sewer is 6 available ^] within 2011 fRet.l �n () U),/ ✓ ( l�P tl✓L0DY1n ,PkaV',C we ?_4J Ql,6E, r�a1' Insulation will serve: Residence_ Commercial_I Other N`t1 Number of living units: I Number of bems droo —L— � � - Character of soil to a depth of 3 feet: L � n Water table depth (2) 6001;No. Compartment SEPTIC TANK O Type/Mfg Capac'?y •Z r PKG. TREATMENT PLT. ❑ Methodof Disposal 3 1 , r`. u.u�1 D'istr`ice t,nearest:. ' `Wells' IOOt.~ Foundation Property Line - 1 ` 'f . LEACHING LINE ❑ No. &Length of lines 17 - QQj Total length/size e FILTER BED ❑ Distance to nearest: Wellevl4't`+.i Foundation Property Line �•' Lt- SEEPAGE PITS ❑ Depth Size SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 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: "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 wbject 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,1 shall employ persons wbject to workman's compensa- tion laws of California." The applic t must 11 a req sed inspections. Complete drawing on reverse side. Signed w Title: FC'1��L�o Dat: FOR DEPARTMENT USE ONLY Application Accepted by '' Data ( D Pit or Grout Inspection by per, Final Inspection by Additional Comments: ❑Stk 466-6781 VLodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant-Return all c6gim to: Environmental Health Permit/Services 16D1 E. Hazelton Ave., P.O. Box 2009, Stk., CA 88201 AMOUNT DUE AMOUNT REMITTED CA RECENED BV DATE PERMIYNO. [I-F4—EE— FO 1 I' •EH 13261REV.i,nm -71, 0C, .7-1 7_I 511 EH W26 - L