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R i .20 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-br No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health Districqt_ Q, y J � -Job Address y�C� - eCity Lot Size �DCS� PM Owner's Name `Ci�.'i;�� • Address 1``t� - �� Phone Contractor Address License No....- Phone TYPE OF WELL/PUIi/IP: NEW WELL_ WELL REPLACEMENT ❑ DESTRUCTION r PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ ER ❑ DISTANCE TO SEPTIC TANKS SEWER LINES --- .._,.___ DI FLD. PROP. LINE t FO ION _. �1 AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE1 TYPE OF WELL, OSLEM A ONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Opeh Bottom Dia. of Well Excavation Dia. of Well Casing ar�restic/Private. V.�❑ Gravel Pa'o ❑ Tracy f Casing Specifications + , F1.,Public f 1` r j Cl Delta Depth of Gro I Type of Grout I t p f ! j I Irrigation _Approx; Dep'th I I Eastern Surface Seal Installed by _ Repair Wor ne ❑ Type of Pump~ > H.P. State Work41 IF W estruction ❑ Well Diameter Sealing.Material (top 507 .. k r Depth � �3 „ Filler Material (Below 50'1 t TYPE OF,SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION 1'1 DESTRUCTION I 1 (No,septic system permitted if public sewer is + Tfr - � - 4/.available within 200.feet.) Installation wiN serve:I Residence Commercial Other``'� •- Number of living units: �Pe Number of be rooms 4 Character of soil to-a depth of 3 feet: I — --- -- — Water table depth SEPTIC TANK ; Type/Mfg l !rCapacityNo. Compartments 02- PKG. TREATMENT PLT. ❑ Method of Disposal al ; op I Distance to nearest: Well Foundation Prlopert-t y Line r� f� LEACHING LINE ' No. & Length of Iines _ LA,D�'tVA-_____ Total length/size ��r �Zt� f � FILTER BED ❑ Distance tc nearest: Well Asa +fit Foundation Property Line 'T � t SEEPAGE PITS Depth -Q&-_Size_ l Number SUMPS L7 Distance to nearest: Well Foundation Property Line k DISPOSAL PONDS; ° ❑ t < t i hereby certify thatI have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, sta't%laws, and rules and regulations of the San Joaquin Local Health District. 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 ih 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 mustcall for'all' squired inspections. Complete drawing an reverse side. } Signed Title: t�3t�P9C ) P� Date: r r g FOR DEPARTMENT USE ONLY f A plication Accepted by Date Area 1MrN�rj:-�R � � Mrf�i�M �.►r.r �/' V f� or Grout Inspection by Dat // Final IInspectii�on; tb 6pi -� D 6 r Additions! Comments € ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 CI Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 955201 e j FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. INFO + EH 13-24(REV.t i 651 7lljjyy . . EH 14-28