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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HA7-EL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMI f 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/cr install the work herei,t 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 h/�/V`0V' City G" �Lot Size PM jOwner';Name = "'� 7 �VA",W' Address ��! /� Phone it Contractor ` ACdress %7" , y� 7 .ty 71-7 7 �''lL`l� License No. Phone i TYPE OF'NELL/PU'AP: NEW WELL U WELL RFPLACEMENT i DESTRUCTION D PUMP INSTALLATION SYSTEM REPAIR C) OTHER O DISTANCE TO K'AREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION __ AGRICULTURE WELL ___ OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS L)Industrial ❑Open Bottom t_1 Manteca Dia.of Well Excavation_ Dia.of Well Casing i [.l Domestic/Private D Gravel Pack L', Tracy Type of Casing _ Specifications Public I-1 Other I-1 flelta Depth of Grout 'eal _ Type of Grout _ I I Inrgabon ____ Approx. Depth I I Eastern Surface Seal Ins -d by_ Rep?ir Work Done f] Type of Pump __ H.P. _ State Work Done Well Destruction LJ Well Diameter —_ _ Sealing Material(top 501 Depth Filler Material(Below 50'1G- TYPE OF SEPTIC WORK: NEW INSTALLATION I I IIEf1AIRrA071TION DESTRUCTION i I INo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence /Commercial—(Other Number of living units: Number of bedJp'm�_/L — — Character of soil to a depth of 3 feet:_ ��L%"!j{ _ Water table depth SEPTIC TANK Ll Type/Mfg _ Capacity____ No. Compartments PKG. TREATMENT PLT.n Method of Disposal V Distance to nearest: Well Foundation _ Property Line r LEACHING LIIJE (' No. S Length of fines ! T9tal length/size j FILTER BED i_I Distance to nearest: Well�n Foundation_ Property Line� s SEEPAGE PITS I I Depth _.Size------ Number SUM?S t 1 Distance to nearest: Weil Foundation_ Property Line DISPOSAL PONDS 1 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 subject to workman's compensation laws of California."Contractors hiring or ub-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 apCrieant must mall for all mgwred inspections. Complete drawing on reverse side. T ,c.�� U w n P C Signed X �"' ____ Title: Date: -,/ r� _ �v��JJJJ DEPARTMENT USE ONLY i Application Accepted by Date /D � Area�/ Pit or Grout Inspection by __. Od:o-_� Finel Inspection by ': jz� Oates D Additional Comments: L 0 Stk ,66-6781 7J Lodi 369 3621 Manteca 823.7104 ❑Tracy 835.6385 ADplizant- Return all copies to: Environmental Health Permit/Serv!ces 1601 E. Hazelton Ave., P.O. Box 2009, Sik., CA 95201FEE INFO AMOUNT DUE AMOUNT RErdrTTEO C K RECEIVED BY DATE PERMIT/NO. . EM 1324 If1EV.r %`%. C t,' ��'I •�`+ EH 14 20