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14 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 San Joaquin Local Health District:" II .-? � ��/ ��5 /`� y � _ C � c� �FFi� PM Job Address Cit of Size Owner's Name S 3 p F. Address-r3s3� _ li�✓�Tr�/G.S , �D Phone S ' Contractor QL1//1L�N- Address ;License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ ",-L f WELL REPLACEMENT ❑ ,DESTRUCTION ❑ U� 1 a. - f• ,PUMP INSTALLATION ❑� SYSTEM,REPAIRX OTHER'D DISTANCE TO NEAREST: SEPTIC TANK ^.SEWER LINES.. 3 FOUNDATION '` AGRICULTURE WELL ) OTHER WELL PITS/SUMPS 4 I i INTENDED USE t TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS I ❑ Industrial 1;!-Op4,,B4ttbm7r ❑ Manteca Dia. of,WelF?_Excavation Dia. of Well Casing ` Domestic/Privates ❑ Gravel Pack ❑ Trac tr `"' 1 f y T ype of�Casing'_YT �. Specifications j ! 13 Public rC7.Othera`] Delta r Depth of Grout Seal Type of Grout � m k _ . El Irrigation ---Approx. Depth C1 Eastern . Surface Seal Installed by 3''. i� 1 ! Repair Work Done ❑` Type'o Pump t HkP. State Work Done_ Y Well Destruction ❑ Well Diameter'A t "" "W" Sealing Material,ltop 501 I Depth Filler Material (Below 501 ^ r1 to'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 Commercial_ Other f Number of living units: --I— Number of bedrooms .. } Character of soil to a depth of 3 feet:} �! - -^ -Water table depth ,•. SEPTIC TANK K Type/Mfg ` Capacity Nod Compo me 1 PKG'TLlREATMENT PLT.Method ofDi to nearest: Well JVD Foundation"-..15x- Property Lined 1 I_^�VLEACHING LINE ' No. & Length of lines o2 /00 Total,length/size --'• �r�.. f FILTER BED ❑ Distance tb nearest: Well Foundation �_-•... Property Line SEEPAGE PITS ❑ Depth +� Size •r,. Number ii )_j +f, p SUMPS ❑ Distance,to nearest Well ° Foundation =Property Line F - DISPOSAL PONDS t ❑ ; hereby certify that I have prepared thisl application and that the work will be done in accordance with San Joaquin county ordinance, state laws, and rules and regulations of the San Joaquin Local Health District. Home owner or licensed agent's signature certifies the following: 'i1`certify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner as toibecome subject to wor&mAn's'compensation laws of California."Contractors hiriri.g or sub-contracting signature certifies the following: "I certify that in the performance of the wffdrork` which tsued;E his pe�mif.is is ,'hall employ persons subject to workman's compensa- tion laws of Cali rnia.':, .,,.J a.� ` ._..a jj ..a _ {- The applicant u t call for all require pections. Complete drawing on reverse side'*, Y X Signed � 'p./7 9 Title: -O!,!/�E Date: } a FOR DEPARTMENT USE bNLY ! r f Application Accepted by L`Pm` `' t Date L-z.-SVIt Area 1. Pit or Grout Inspection b Date Final Inspection by Date Additional Comments: ❑ Stk 466-6781 [❑ Lodi 369-3621 ❑ Manteca 823-7104 C3 Tracy�835-6385 j 'Y Applicant- Return all copies to: Environmental Health Permit/Services.1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE f AMOUNT REMITTED CAH RECEIVED BY. DATE "� PERMIT"NO. S � a!EH 13-24 4REV.1/H 51Vo .EH 14.26 1