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APPLICATION,FOR PERMIT t- SAN JOAQUIN LOCACHEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON' CA Telephone'(209) 466-6781 I PERMIT EXPIRES...1 YEAR FROM DATE ISSUED 'q (Complete in Triplicate) Applicin ation is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described.y'This application is made 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 y { Job Address City Lot Size PM Owner's Name 'Address ja { - Phone 3 Contractor Address Ir ,. TYPE OF WELL/PUMP: License No. Phone NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION p I i� PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ DISTANCE TO NEAREST: SEPTIC TANK OTHER ❑ SEWER L1NES DISPOSAL FLD. PROP LINE ^ FOUNDATION AGRICULTURE WELL t 4 �� OTHER WELL PITS/SUMPS ' fNTENDED USE �. TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial 0 Open Bottom ❑ Manteca 1 Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy T (1, El Public Type of Casing Speciftcations ❑ Other ❑ Delta Depth of Grout Seal ❑ irrigation ---Approx. Depth ❑ Eastern TYPE of Grout y�) Surface Seal Installed.by i 1 "' Repair Work Done ❑ Type of Pump H.P. :E`, a4 State Work Done_ Well Destruction ❑ Well Diameter Sealing Material (top 50') .i i Depth Filler Material Melow 50'l TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION DESTRUCTION ❑�iNo septic system permitted if public sewer is Instailation will serve: Residence x available within 200'feet.l Commercial! Other '._;,! Number of living units:_L Number of bedrooms_� _ Character of soil to a depth of 3 feet: SEPTIC TANK 'X Type/Mfg ell- f Water table depth j PKG. TREATMENT PLT. ❑ Capacity ZDO No. Compartments 1 Foundation � Q t Method of Disposal Distance to nearest: Well l r r c �t Property Line LEACHING LINE �' No. &L'en th of lin s t�'-.� "' –`"•"` '- FILTER BED Tota! length/size ❑ Distance to nearest: "grail t , r Foundation—�1 ProirtY Lin . •a _ -7> .- \ 1 SEEPAGE PITS y - j �'. Depth �� ' Size F � ��. SUMPS- Number ❑ Distance to nearest: .–Well �� 1 ", {,�• DISPOSAL PONDS ❑ Foundation l90 i PropertY3 Line _ hereby certify that I have re p pared this application and that the work will be done in accordance wite§an Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. r Home owner or licensed agent's signature certifies the following: "I certify that in the the h }�� for� employ any person in such manner as to become subject to workman's compensation laws of Califomiahg}Coni actogr's whichthis or sub-contracting signatnot ure certifies the followi : "I certify that i he performance of the work for which this permit is issued, i shall employ persons subject to workman's compensa tion laws of Calif nia." The applicant st cal or all r ired inspections. Complete drawing on reverse side. Signed n - Title: —_�1s„l�.o { r Date: FOR DEPARTMENT USE ONLY r - , Appl' ation Accepted by s Date r' o ] Area Pit or G►out inspection by �� Date . Final inspei;tion by � Date Additional Comments: ❑-5tk_46"781_,;-O-Lodi–369-3621_,.El_Manteca —823-7104,,C] Tracy- Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. azelton Ave.,8P50•'Box 20pg, 5ik., CA 95201 INFO AMOUNT DUE. AMOUNT REMITTED H RECEIVED BY DATE PERMIT'No. '+ EH 13-24 IREV.'s EH 14-28