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APPLICATION,FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT ' 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 I PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) 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 IE 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. City Lot Size PM Job Address . 4f Addres�� Phone .., Owner's Name - _-_-_ + hone I t V1 Address_ Bi' License No. Contractor _ TYPE OF WELL/PUMP: NEW WELL ❑ y "'-'^-WEL•L REPLACEMENT Ll DESTRUCTION ❑ PUMP INSTALLATION ❑ -t'- -SYSTEM-REPAIR-C "—_ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES,-,-' DISPOSAL FLD.ff PROP. LINE fi } - k `-� FOUNDATION AGRICULTURE WELLN, OTHER WELL PITS/SUMPS INTENDED-USE— " TYPE bF"VVEL""L-" PRO'BLEM AREA 1 CONSTRUCTION SPECIFICATIONS I ❑�Manteca Dia. of Well Excavation —- Dia. i f Well Casing ❑ Industrial ❑ Open Bottom,,,, �'� w j ' r" Type of CasingSpecifications 0 Domestic/Private ❑ Gravel Pack ❑ Tracy � ^� Type of Grout R e t 1 % -�•w-�- '" "'❑'Delta Depth of Grout Seal ` F?ublic ❑-Other z +� a� ❑ Irrigation _ ApProx. Depth ❑ Eastern Surface Seal Installed Repair Work Done ❑ Type of Pump P. State Work Dane x 1 f Well Destruction`LI Well Diameter `Sealing Material trop 50'1 ' Depth `Filler Material (Below 50°1 t , `TYPE OF SEPTIC WORK\NEW INSTALLATION ❑ REPAIR/ADDITION. DESTRUCTION ❑ INo"septic system permitted if public sewer is t�available within1200 feet.) �"� � (Commercial_Other Installation will serve: Residence� t t '"—Number of Irving unit Number of bedrooms - k Cha acter of soil to a depth of 3 feet: t Water tale depth .r SEPTIC TANK ❑ Type/Mfg -v. y Capacity i"t.7I No Compartments k Method of Disposal PKG. TREATMENT PLT. ❑ �If":.I Distance to nearest: Well Foundation Pr perty Line LE C ING LINE No. &Length'of lines 4 c oral length/size I l i t t j > FILTER,BED ❑ Dunce to nearest: Well/D O -IFvundation d Property Line �.r.f SEEPAGE P{TS lJ Depth a Size �L Number SUMPS - Distance to nearest: WeIIL. [L44Foundation� Property Line DISPOSAL PONDS ❑ p I 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, an "rules andtreoulations of'the,§an-J.oaquin Local F�ealth,District. Home owner �'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 (i i employ any person it sdch-manner as tonhecome subject to workman's compensation laws of California." Contractors hiring:or sub-contracting signature certifies the following:"I certify that in the performance of the work for which this permit s issued, I shall employ persons subject to workman's compensa tion laws of California." The applicant must�ca_II for all required inspC ions. Complete drawin�on reverse side. �+'"' tle: � �, Ti ,. °A i r3i'�7-� Signed-X._ _ RRDEPARTMENT USE'ONLY Area Application Accepted by " j `:.__ t�;;f — Final Inspection by Date Pit or Grout Inspection by Date 1 Additional Comments: n ❑ 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 200, Stk., CA 95201 EINFO CK RECEIVED BY DATE PERMIT NO. �'-AMOUNT DUE AMOUNT REMITTED CASH Aq ��(yEH 13-24(REV.1/H 5) •�� !! EH 14-26 ! Y _ .