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I, I APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZETON AVE., STOCKTON, CA _ Telephone (209) 466-6781 II a" PERMIT EXPIRES 1'YEAR FROM DATE ISSUED r h (Complete in Triplicate) tApplication is hereby made to�xhe San Joaquin-Local Health District for a permit to construct and/or install the work herein described.This application is iy for sewage or.No. 1862 for well/pump and the Rules and Regulations of the San Joaquin made in compliance with San Joaquin County Ordinance Na.549 Local Health District. i x Job Address City Lot Size t JC- ((�� ,- — � Phone Owner's Name.� O �1C4. �'L Address. .Co nt�racl (+h Address ' �{ License No.3--- 21(8 Phone `V TYPE OF WELL/PUMP:—NEW WELL ❑ WELL REPLACEMENT .❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑* OTHER;❑ DISTANCE TCI NEAREST: SEPTIC TANK SEWER LINES D1SP05AL FLO. PROP: LINE <' FOUNDATION AGRICULTURE WELLn OTHER-WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA COI STRUCTION-SP IFICATIONS ❑ Industrial EI.-Open Bottom ❑ Manteca ''°Dia lof Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack © Tracy ;Type of Casing ` Specifications # t l`l Public i_l Other ❑ Delta r'-',� Depth of Grout Seal Type of Grout _. I I Irrigation _Approx. Depth I 1 Eastern f "S[Aace Seal-Installed Uy`-7 Repair Work Done ❑ Type of Pump H.P. '- '- State Work Done_ Well Destruction . ❑ Well Diameter ` -5ealing-Mat6ribl (top-501 • Depth ler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION I.1 REPA1 ADDITION l_ DESTRUCTION I I (No septic system permitted if public sewer is ' t $ .�. , F # available within 200 feet.) Y Installation will serve: Rep`idence Commercial_ Other, {" Number of living units Number droom` x o Character of soil to a depth of 3 feet: " _. Water table depth SEPTIC TANK ❑ 1' Type/Mfg i � `x� - Capacity No. Compartments _ t PKG. TREATMENT'PLT. ❑ i� i, Method of Disposal I Distance to nearest: Well -"' 'Found-atioin '---'Pioperty Line r LEACHING LINE C<No. & Length of lines _ ' 46 _ Total length/size �Q X FILTER BED ❑ Distance to nearest: WellFoundation, �� Property Line 1 SEEPAGE PITS I li Depth 105 Size—_..I Number SUMPS CCl Distance to nearest: Welt 100" Foundation ti Property Line DISPOSAL PONDS �;� I hereby certify that'I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations'of,thetan 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.110nner 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." The applicant ca11 for Vgeqed inspections. Complete drawing on reverse side. I Q Q Title: ! ^ Date: Signed X - i , FOR DE RTMENT USE ONLY Application Accepted by � ' Date S I/ Area Pit or Grout Inspection by I Date Final Inspection by V"lS � b �taf Date_7_—/� ' - 1 Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 0 Manteca 823-7104 O Tracy 835-6365., Applicant -Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 3 'Y V INFO[. FEE AMOUN DUE AMOUNT REMITTED' SASH RECEIVED BY DATE` PERMIT NO. /}} + EH 13-24(REV.i/n sl iI EH 14-2e+ '�\