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APPLICATION FOR PERMIT r SAN JOAQUIN LOCAL°HEALTH DISTRICT } ,1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone {209) 466.6781 PERMIT EXPIRES 1 YEAR`FROWDATE ISSUED` (Complete in Triplicatef Ma I 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 Jdaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Ryles and Regulations of the San Joaquin 'Local Health District. + 4 year . _ Jv� a Job Address r.: e!j� 2j .le p City Lot Size 'PM �-•� Owner's Name _ Address{ — Phone - Contractor Address Coe /9Tc�.r4 Licens e No. tea ..P ane TYPE OF WELL/PUMP: I� NEW WELL ❑ ;WELL-REPLACEMENT ❑"'W-` `F"DESTRUCTION-El —*- PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER'❑ %s rah DISTANCE 70 NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD; A '-"� W PROP: LINE. FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS r INTENDED USE TYPE OF WELL PROBLEM AREA 'CONSTRUCTION SPECIFICATIONS— Ll Indusfribi PECIFICATIONS—LlIndustrial ❑'0 en Bottom Manteca i Dia. of Well Excavation ` ;Dia. of Well Casing ❑ Domestic/Private L1Gravel Pack ❑ Tracy Type of Casin .-:? '''-� Specifications ❑ Public g e 4 Specifications ❑ Other ❑ Delta Depth of Grout 5eal� # 4x r ❑ Irrigation Type of Grout 9 �pprox. Depth ❑ Eastern Surface Seal'Iristalled by '� N,'Y --' -- -=- - Repair Work Done El Type of Pump `_ H.P. State Work Done J".~ Well Destruction ❑ Well Diameter ,8ealing'Material•.(top 50') I t Depth' Filler Material'(Below 50'i� rTYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ DESTRUCTION`[] (No septic system permitted if public sewer is 1 �t w,y k t' a�\., v y. 1\ } t 4- P Y 4 ; st Y rt available within 200 feet ) t Installation will serve: Residence ; Commer ial' Other " ` M .�^' ..4: "N. -�.- ='--r ; i��_�,-"} - 'x-�, _ --:.tom' Number of living units: Number of bedrooms x t Character of.soil to_a depth-ofl3'feet: .t' SEPTIC TANK ❑ ' Type/Mf , � E Water table depth C- V� �„ ��tio' ,'� g } Capacity No. Compartments PKG. TREATMENT PLT. ❑ ,iI�1 t � i t : t _ (b Method-of-Dspc op Di,: Foundation Property Line 1. LEACHING LINE ❑ :`No, t dI& Length of lines �"Total length/size pstance to.neares,t:-sFILTER i Foundation-/ly Property Line._;I;;ir'a r j SEEPAGE,PITS ❑ DepthSite Number ) SUMPS ❑ Distance to nearest: Well Foundation Property Line- t DISPOSAL PONDS ❑ �� I hereby certify that I have prepaied this application and that the work will be done in accordance with Sari,.Ioaquin county ordinances, state laws, anc rules and regulations of the San Joaquin Local Health District. >F 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 riot 4 employ any person in such manner as to became subject to workman's compensation laws of California."Contractor's hiring or sukrcontracting signature certifies the following:"I certify that in the performance of the work for which this permit is issued, !shall employ per tion.laws of California." sons;subject to workman's compensa The applicant must call for all jyir r q s pections Complete drawing on reverse side. _ ¥ Signed Tit le:"--" DateT YAg FOR DEPARTMENT USE ONLY Application Accepted by �� • ' r Date .7 -,r!r Area Pit'or Grout Inspection by Date ' Final Inspection by i Dated E Additional Comments: a ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 623-7104 ❑ Tracy 835-6385 �.. 'Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AM0UNTI�DUE -� AMOUNT REMITTED CK,. TM RECEIVED BYDATE INFO CASH _ PERMIT"NO. +EHt3-24(REV.t�851""' "'_ �i`f, ' `.' -- --- - - EH 14-26 - `5x�k8l- 4.r