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e APPLICATION FOR PERMIT '��' SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAzEL.tQIVAV�E., STOCKTON, CA one p Tele h 12091 4"66-6781 t PERMIT EXPIRES I'YEAR FROM DATE ISSUED `� C (Complete in.Triplicate) 4 Application is hereby made to the San Joaquin Local Health District for a permit to construct and/of install the work hereX4A611QWj1TNTappliHt+dti`- H made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 fqr vyelUpumd the Rules and RegTVR4, nfAPff-RV1@ESin _ Local Health District. ` //S`/ ,�0►/ �1/w Job Address City C •ot Size PM !�!� t1G Address /`iP � a©A7Phone Owner's Name r C Contractor 2-,;-o�w Address � 4f H l L (0� License No. 3 Phone —9-610? TYPE OF WELL/PUMP:, NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION_ AGRICULTUREWEL-L— ---..OTHER WELL _ P-I.T_S!SUMPS. INTENDED USE j TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS _ ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Grbvel Pack ❑ Tracy Type of Casing Specifications F3 Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout I I Irrigation Approx. Depth I.I_Faster Su ce Seal Installed by Repair Work-Done Type p S ti 5' Stat Work Done . � f� 7 e of Pum � H.P. �i•- �. ' Q� +� Well Destruction ❑ Weil Diameter '1 J_ i Depth Filler Material IBelow50'1 tf' t e TYPE OF SI}PTIC WORK: NEW INSTALLATION 1.1 REPAIR/ADDITION I I DESTRUCTION 1`1 Mo septic system permitted if public sewer is w } available'„within 200 feet.I fl InstallationNwill serve: Residence_ Commercial_ Other i C1 Number 6f,living units: Number of bedrooms Charactefo f soil to a depth of 3 feet: - :Water table depth SEPTIC TANK n ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. O IMethod of Disposal a. t\tea Distance to nearest: Well Foundation Property Line I i S LEACHINGLINEI ❑ No. & Length of lines Total length/lze FILTERBED,` ❑ Distance to nearest: Well Foundation Property Line , - °SEEPAGEPITS r I I DepSize ' Number SUMPS 1 ❑ Distance to nearest: 1Nell” F undation Propeq Line DISPOSAL PONDS I hereby certify thatil have prepared this application and that the work will ba done in accordance with San Joaquin county ordinances, state.,laws, and rules and reg ns `San Joaquin-.Local-Health-Di-trict -- -�.�-----�- — ---� r Home own or licensed ag is signature certifies_ followirig:,"l certify that in the performance of the work for which this permit is issued, I shall not r i" 1t , * ., . i employ a person in such m nner as to b om uti' v kman's-bdmpensatidn awsbf California." Contractor's hiring or sub-contracting signature certifies t e following: "I certi t t in! pe c ft wort is per. ' issued, I shall employ persons subject to workman's compensa- tion laws of California The appl ant m st r requ' omplete rowing on rev Signed X: Title: Date: Arl r FOR DEPARTMENT USE ONLY Application Accepted by Date Area Pit'or Grout Inspection by Date Final Inspection by Date Additional Comments: T/❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 IFEE NFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. +.EH 13-24 tREV.I H 5) `�C A Q P EH 14-26 J Y F,