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I~ APPLICATION FOR PERMIT } SAN JOAQUIN LOCAL HEALTH DISTRICT �f 1601 E. HAZEL.T ON AVE., STOCKTON, CA Telephone (209) 466-6781 l PERMIT EXPIRES 1 YEAR FROM DATE ISSUED r (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. Job Address �e_ City C^-' LotSize /✓'D Tk M t �,Y 1 n 93/-. Owner's Name �^^� a�A.�_ _- Addressw�/ � �IaY�.JrY)Q9/�_ ` Phone /7 Contractor U v►. Address k License No. 7Phone 46 6 r b Z TY.PE_OF_WELL/PUMP:__.—NEW.—NEW.WELL I❑-- 'WELL REPLACEMENT-E] -DESTRUCTION ❑ PUMP INSTALLATION LIQ SYSTEM REPAIR.❑ 'O+HER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES __ DISPOSAL FLD.— ? PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL ' PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS t O Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑Tracy Type of Casing Specifications Fl Public C1 Other I� Delta Depth of Grout Seal Type of Grout _ rrigation ,// _..Approx. Dept-Eastern Surfac Seal Installed by Repair Work Done L7 Type of Pump . H.P. S� State Work Done '_ hSAD, Well Destruction ❑ Well Diameter" Sealing Material (top 50') �T Depth Filler Material (Below 501 f TYPE OF SEPTIC WORK: `'NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION I I INo,septic system permitted if public sewer is �•� * r — available within 200 feet.) I a. f — Installation will serve: Residence__? Commercial,. Other=- - 'rt -• , \ i1 Number of living units:_` Number of bedrooms ty' i Character of soil to a depth of 3 feet: "'i _ Water table depth j SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal T- ` ' Distance to nearest: Well and n Property Line t� LEACHING LINE Cl No. 8 Length of lin14." Total lengthlsize - ' ti 1 FILTER BED C] Distance to neare's Well Foundation Property Line SEEPAGE PITS i I Depth, ize Numbe SUMPS LI Distance to neare Well "'" Foundation �Prdpe Line__ l DISPOSAL PONDS ID 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, an rules and regulation San Joaquin Local Health District. Home owner or ensed ago is sinature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not aps3m.�u becom ject to workman's compensation laws of California." Contractor's hiring or sub contracting signature certis nge rf nce of the work for which this permit is issued, I shall employ persons subject to workman's compansation law �n'The appctions. e e yawing on re de. ' Date: ZoSigned _ __ Title: R DEPARTMENT USE ONLY Application Accepted by _ Date b" 1 Area Pit or Grout Inspection by Data_ Final Inspection by Date I a Additional Comments: t O Stk 456-6781 Ll Lodi. 369-3621 C7 Manteca 1123-7104 ❑ Tracy 835-6385 �- Applicant - Return all copies to:-Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Sik., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED` C$H`_ _ -RECEIVED-BY --; DATE._, PERMIT NO. INFO .EH 13.241REV.lin s) 4�4E �S _ ._ __. —_ _ '1� EH 14-26 t •`