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I 3 APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT < 1601 E. HAZEL I ON AVE., STOCKTON, CA i Telephone (209) 466-6781 PERMIT EXPIRES 'I 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. 1852 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. 41 Job Address O` Iffly ©ice City "C Lot Size ,73l11� PM (Mn4et/14�I�/P'T.� - SDS f " l Phone ` 1 s`�� Owner's Name Address --.. Contractor s Cl - Address License No. Phone fl TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION 0- PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ -' OTHER ❑ E DISTANCE TON T: SEPTIC TANK SEWER LINES ISPOSAL FLD. PROP. LINE F TION AGRICULTURE WEL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WEL ROBLEM AR ONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ M Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack Tracy yp sing Specifications x ❑ Public ❑ Other D Delta Depth'af Gout a 1-�- , Type of Grout ❑ Irrigation _.�Approx.•Depth D Eastern v4 ,. Surface Seal Installed by -- ` F Repair Wo Done Type of Pump H,P. State Work Done Well Destro on ❑ Wel! Diameter . Sealing Material (top 501 ' 1 Depth 1 Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTIO (No-septic system permitted if public sewer is € II X,7*ailable4vithin-200 feet.) i Installation will serve: Residence_ Commercial'`_ Other Numberjof living units: Number of bedrooms w ` ✓ Character of soil to a depth of 3 feet: `" _ Water table depth ' I1 SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ : "" '` " `� '—� t Method of Disposal __ t Distance to nearest: Well Foundation'21Property Line 6 ' LEACHING LINE ❑ No. & Length of lines Notal length/size ` t FILTER BED' < ❑ Distance to nearest: Well Foundation Property Line SEEPAGE.PITS ❑ Depth `' Size `} Number :SUMPS ❑ Distance to nearest: Well Foundation Property Line `-DISPOSALS PONDS._ ❑. .: fI hereby certify thai_Thave 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'"Flealtli`District'" 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 in 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." : a € The applicant st call for all re i ctions. C mplete drawing on reverse side. �- sr Signed '� "'� Title: �cu��— Date: FOR DEP RTMENT USE ONLY ` � � I I Application.Accepted by Data Area Lei_ I Pit orlGrouInspection by Date Final Inspection b4Z Additional Comments D ❑ Stk 468-6781 ❑ L6di 369-3621 ❑ Manteca 823-7104 '❑-Tracy 835-6385 f Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 k FEE i € INFO AMOUNT DUE AMOUNT REMITTED K RECEIVED BY DATE PERMIT'NO, l + EH 13-26 REV.€/e 5) t 'R734 �4 !f EH 10.28 i+