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C APPLICATION FOR PERMIT r • - . . SAN JOAQUIN',LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209)1466-6781 PERMIT EXPIRES 1,YEAR FROM DATE.ISSUED %,, , Ac Triplicate} .,:; Ci+iT ci �cCVPw 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. V ,�• r F ! x.iE op , #' -1.,.`. -Ety �' p t",.C, T'• s1 .. �..] 1E V City Lot Size S7rC�4/ ._. PM Job Address Owner's Name �ddress __ one Contractor's flame License No. Phone TYPE OF WELLIPUMP: NEW WELL ❑ WELL REPLACEMENT ❑ ' DESTRUCTION ❑ ' PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD, _ PROP. LINE n FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS Vv INTENDECUSE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation. Dia. of Well Casing '❑ Domestic/Private 11 Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other -❑ Delta Depth of Grout Seal Type of Grout ' ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done . Well Destruction ❑ Well Diameter Sealing Material {top 501 ` Depth Filler Material 113el9w 501 _ 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 Number of living units: Number of bedrooms Character of soil to a depth of 3'feet: Water table depth SEPTIC TANK ❑ Type/Mfg _Capacity No. Compartments PKG. TREATMENT PLT:L] 1 t Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING"CINE"�"�W No. & Length of lines Total length/size -R FILTERtBED '❑ Distance to nearest: Well, Foundation Property Line SEEPAGE PITS Depth a- Size t X � Pumber� t * _ I SUMPS =11 Distance to nearest:' Well r 4<Foundation ` / Property Line 29 DISPOSAL PONDS "❑ - : hereby certify:that+-have prepared this application and that the work wilf.be dorie in accordance with San Joaquin county ordinances, state laws, and rules and regulations of tfe San Joaquin Local Health 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 s ibject'to�workman's compensation-laws.of California."Contractor's hiring or sub-contracting signature certifies the following:"I-certify'that in„the perforinance-of the-iAt6rk forwFiich-this:permit is issued„I ihall-employ persons subject to workman's compensa- F .tion laws'of-California” y _ ._ t o.- t-Y t. a ' The appfiean irm call far all uired inspecti ns. late drawing on verse side. f. - _ y Signed X� —d� itle: }} rDate: /rte— i 'f t ��FiOR�DEPARTMENT USE ONLY ' S Application Accepted by i Date - Area Pit or.Grout Inspection byate Final Inspection by Date 'Ad onal Comments: 466-6781 r - 13-Lodi” 36.9-3621 -El Manteca 823-7104 -* ❑'Tracy 835-6385 f Applican - Return all copies to: Environmental Health Permit/Services 1601 E. Hazetton Ave., P.O. Box 2009, Sittk., CA 95201 t FEE, FIAMOUNT DUE AMOUNT REMITTED K RECEIVED tY DATE PERMIT'NO. f INFO I '+ EH 13-24(REV 10!631 r EH 1426 A— ,�r _�.✓,,.. 4__�. - lY a-•�--i: -... �N:/ «----+,e -.1.-x•12= '- -" + �f' .. - """