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APPLICATION FOR PERMIT SAN JOAQUIN`LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE.,"STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED-" tbcat 10 allos " 14 (Complete in Triplicate) 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 District. ICity' 3fi 'Lot Size PM Job Address �_ PhonAWU�Z -AddressOwner's Namer~ � k r /j� Contractor --Address ,.�,. - � �- License N�� _Phone (3 f� ' TYPE OF WELL/PUMP: N'EW WE4 O.. . .Z �WELCREPMCEMENT ❑y � DESTRUCTION 13--r-:�i' l PUMP INSTALLATION:D't. SYSTEM REPAIR El OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK Q.vSEWER`LINES' DISPOSAL FLD. PROP. LINE I WYt ;;9`,.FOUNDATION AGRICULTURE;VIIELL OTHER WELL PITS/SUMPS INTENDED USE-' 0,1 'TYPE"OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation c, Dia. of Well Casing ❑ Domestic/Private D--Gravel Pack ❑ Tracy Type of Casing "` _' Specifications ❑ Public CD Other - ,❑ Delta -Depth of Grout-Seal ; �'R fI Type of Grout irrigation t�f HiQ '�!Approx. Depth ❑ Eastern Surface Seal Installed by pair'Work Done,.. 3 p Type of Pump H.P. 4 State Work-bone Lr! Well DestructiiinRL 0..—.Well DiameterSealing-Material-Itop 50'I% Depth Filler Material Melow 509 ' r TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION-I] DESTRUCTION6.1No septic system permitted if public sewer is available within 200 feet.) k Installation will serve: Residence_ Commercial_ Other kl Number of living units: Number of bedrooms t Character of soil to a depth of.3 feet:: 4 Water table depth SEPTIC TANK Type/Mfg No. Compartments PKG. TREATMENT PLT. ❑ � t'Method of Disposal Distance to nearest: Well Foundation Property Line f # U i l '• r LEACHING LINE-- --�'❑w-No &-Length of lines- Total"lerig#h/size 4 5-..e r_ i.. FILTER BED ❑ Distance to nearest: Well Foundation_ a` P�ro�perty Line SEEPAGE PITS ❑ Depth Size4- Number_L! SUMPS 11 Distance to nearest: Well Foundation �'�'pProperty Line T. . .: - i 'f 5-'3 wti (;' 'ii , 'dry, '' °r- DISPOSAL PONDS 'Jo `� '` Thereby certify that I have prepared this application and that the wbrk•'w'i11Lbe.done:in accordance.wiiWa'n Joaquin county ordinances, state laws, and t rules and regulations of the San Joaquin Local Health Districi:.N,,e ,.;V. -J t~^� c;� f, '"<'• • Home owner or 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 work man's•compensation laws of California.w Contractat's hiring or sub contracting signature certifies the following:'"t_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 11�t0c[al�f�r/ValI requir spectt ns .Complete drawing-on reverse de. In Signed ✓� - Date: 7a7/"�- a OR DEPARTMENT USE ONLY a i• Application Accepted by `17 �. T a ' Date S Area <, . 0 " } + .� W Dai f`- Final Inspection by C_ Rate lQ Pit'or Grout Inspection by —Additional"Comments:^----^-- ❑ Stk 466-6781 ❑ Lodi 369-3621, ❑ Manteca 623-7104 ❑Tracy 6355-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 IFEE NFO AMOUNT DUE I AMOUNT REMITTED CASH RECEIVED BY . DATE PERMIT"NO. + EH 13-24(REV.1/851 ' ' `+�- O �— EH 14-26