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Y ti d 7 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/ ump and the Rules and Regulations of the San Joaquin Local Health District. f �,� l / I � i Job Address e4�r Vff /�� '�� City Lot Size �AzeoQo!"E PM f�rwPLsAlasa -�-�EY �!� Addzesc ` Phone y� n t2� l� !+%a /7� Lce 2:- 3°Anse % ?� Phony 1 Conlraotn -L-S ddre TYPE OF WELL/PUMP: NEW WELL-❑ WELL REPLACEMENT-E] _ 'DESTRUCTION ❑ r j PUMP INSTALLATION ❑ L SYSTEM REPAIR-0 OTHER ❑ 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 ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation f Dia. of Well Casing ❑ Domestic/Private ❑ Graver Pack ❑ Tracy Type of Casing * +} ' ' e Specifications r] Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout I I.Irrigation —Approx. Depth l I Eastern Surface Seal Installed by _ t� Repair Work Done ❑ Type of Pump H.P. State Work Done ---i ' Well Destruction ❑ Well Diameter Sealing Material Itop 501 _ to Depth Filler Material (Below 501 R r N TYPE OF SEPTIC WORK: NEW IN STA LLATIO REPAIR/ADDITION f I DESTRUCTION I I lNo septic system permitted if public sewer is I I available within 200 feet-I ilnstallatiori will serve: Residencemmercial— Other Number of living units: -.2— Numberq bedrooms Character of soil to a depth of 3 feet: 1Zf'`+ Water table depth SEPTIC TANK Lai'Type/Mfg 4MA "V- / Capacity-0420— 49 No. Compartments CX PKG. TREATMENT PLT. ❑ �/04P0 Method of Disposal Distance to nearest: Well�,1 _._.._ Foundationa s Property Line 1110444 LEACHING LINE No. & L'ength of lines _� -Or=�� Total length/size 1 d } FILTER BED ❑_Distance to nearest: Weil '01 "71 Foundation fd r i Property Line 'Id t q� 0 - Size Number 1 "SEEPAGE PITS � f I ' Dbe ept �-_.�5 � ' � �' � ' � iSUMPS t Distance to nearest: Well / -a Foundation� Property Line DISPOSAL PONDS ❑ f tW + 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. t + 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,-)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 r= 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 Crali a.-" i 1 Theapplicant us all f all requir d inspections. Complete drawing on reverse side. t I Signed X Title: 11 Date OR DE RTfNENT USE ONLY Application Accepted by Date Area Pit or Grout Inspection by a Final Inspection by Additional Comments: ❑ Stk 466.6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 i z IFEEO AMOUNT DUE AMOUNT REMITTED CA8H RECEIVED BY DATE PERMIT NO. + EH 13-24(REV.t i x 51 EH 14-28