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r APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 4r 1601 E. HAZEL f ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES'1;YEAR'FROM' DATE ISSUED (Complete in,Triplicate) 'Z, -.+. .. ¢ �. 4.x• 7 ., f R .. F.. .k ,: t E r f 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 Ryles and Regulations of the San Joaquin Local Health Disfrict. ` 4 Job Addresst L6 5. _ A: s City ft .. Lot Size'--' *PM Owner's Name + BD/+l ;.._ :. Address•-S �. _ ,-.. �.�� s �9 Phone ' Contractor Address License No, Phone TYPE OF WELL/PU NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR,❑ OTHER ❑ —DISTANCE TO NEAREST'SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION-SPECIFICATIONS ❑ industrial ❑ Open Bottom : i E Mantecay : r Dra.;of Well Excavatio —,— -- t..T:.�, f Wel_ xca' - P Dia. of Well Casing ❑ Domestic/Private ❑ Gralliiel Pack 13 Tracy ' " " ` y I Type of Casing i Specifications ❑ Public- ElOther ❑ Delta � � Depth of Grout Seal ❑ Irrigation —_qf r`' 1: ' Type of Grout ---Approx.'Depth ❑ Eastern Surface Seal Installed by Repair Work Dane ❑ Type of Pump."- H.P. � - State Work Done Wel! Destruction ❑ Well Diameter Seng Material [top 50') \ Depth Y`°->r - :Filler Material f Selo TYPE OF SEPTIC WORK: NEW INSTALLATION LI REPAIR/ADDITION ESTRUCTiON ❑ (No septic system permitted if public sewer is available`within 200 feet.) Q� Installation will serve: ResidenceCommeicial Other Number of living units: �� 'Number of bedrooms C-7- Character of soil to a depth of 3 feet.;- Water table depth ? SEPTIC TANK ❑ Type/Mfg4 Ca Capacity. a �.: p y No. Compartments PKG. TREATMENT PLT:❑ _ - 4c�'" � ' 1 Method of Diisposal Distance to nearest: Well Foundation Property Line s t LEACHING LINE + �No & Length of lines �l d Total lengtfl/size d tt FILTER BED ❑ Distance to nearest: Well Foundation�l3 property Line 02 SEEPAGE PiTS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation_ Property 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 the 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 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 must call for all required inspections. Complete drawing on reverse side. ¢ Signed Title: Date } FOR DEPARTMENT USE ONLY Application Accepted by Date Area Pit or Grout Inspection by Date Final inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 'NTracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 z'Ito n Ave., P.O, "Box 2009, Stk„ CA 95201 : FEE INFO AMOUNT DUE AMOUNT REMITTED RECEIVED BY_ DATE PERMIT'N0. +EH 13-24(REV.t/as) � EH W26 { .