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�t '•oo 3a APPLICATION FOR'PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA ` Telephone 12091 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 San Joaquin Local Health District. ,�,,,,p Job Address 7p ft�Iirl, Ur' �icr��ityy"_?!�Al�-"VLot Size PM Owner's Name .( 9Address.M'��"�/'7 `~ Phone Contractor's Name A9, 4eR_-_V_& 1f° J' ,W License No. .3 V3 Phone 1,6 i� Z4 D TYPE OF WELL/PUMP: NEW WELL ❑ ? WELL REPLACEMENT ❑ DESTRUCTION ❑ j PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ O DISTANCE TO NEAREST: SEPTIC TANK +'SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS h INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS .40 ❑ Industrial - 13 Open Bottom El Manteca Dia. of Well Excavation Dia. of Well Casing 4 ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by ; Repair Work Done . ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 i Depth Filler Material (Below 501 - TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ CommercialOj Other .... ....�..�.,�,- _ Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK kr'�`Type/Mfg /T 6Z Capacity /�2Q Q No. Compartments 2- PKG. TREATMENT PLT. ❑ i Method of Disposal I Distance to ne res Well A0'12- �-Foundation Property Line LEACHING LINE No. & Length of lines TO Total length/size 14Kd e FILTER BED ❑ Distance to nearest: Well Foundation - ![) Property Line Z� f - ..�.� SEEPAGE PITS ❑ Depth Size Number' SUMPS ❑ Distance to nearest: Well Foundation Property Line jY DISPOSAL PONDS' ❑ ,. 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: I % I 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-fF 5t call for all required inspect ons. Complete drawing on'revemeside. *;^� •, Signed X7 Title: Date: . FOR DEPARTMENT USE ONLY`' ¢ Application Accepted by Date Area !Z Pit or Grout Inspection by Date Final Inspection by Da Additional Comments: nlc_ ID Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca -7104 ❑ Tracy 835- } Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk. CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED r�/Cy.l(K RECEIVED BY DATE - PPERMI-yT'N`O. + EH 1324 IRM 10/831 `�' .. 1. 1 N� �---�-� ` �`v0 EH 1428