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APPLICATION FOR PERMIT SAN JOAQUIN 12OCAL�HEALTH DISTRICT 1601 E. ,HAZE�TON AVE.,-STOCKTON, CA Telephone {2091 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ... ., " A 4 (Complete in Triplicate) :.. 4 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 Rules and Regulations of the San Joaquin Local Health District: buKr e%, ti :. . Job Address -7 spm" -City 5f_0 CM!!, Lot Size PM Owner's Name e° -Ae-&--C_0Address rlrV- ST—* 060%Phone C) " d��.. Q 4S�.st ss D►��r-�sTe5v;5ACj C*/ C A 36G--1 Contractor I%c*ddress a icense No. Ph TYPE OF WELL/PUMP: NEW WELL pKkWELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ A -net OTHER BGIINAs DI§TANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE I �'FOUNbATION- � AGRICULTURE WELL OTHER WELL w...BITS/.SUMPS r d INTENDED USE L_,.T,YPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIO Ii � � 41 [b,Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation_ _ Dia;-of-Well Casing r 0?pomesticlPrivate ElGravel Pack ❑ Tracy Type of Casing _Specifications ! r 67 Type of Grout []'Public 66Other�� I''� ❑ Delta Clepth of Grout Seal `� yp r 0 Irrigations. —Approx. Depth ❑ Eastern Surface Seal Installed by CPaf_-& ery. y Repair Work Done El Type of Pump _ NIH.P. State Work Done j WeII Destruction ❑ r.WelhDiameter sealing Material ifop 501 t F pepthFiller Material Ieelow 50'7 TYPE OF SEPTIC WORK: %AlEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ IND septic system permitted if public sewer is available within 200 feet.) b Installation will serve: Residence— Commercial Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth R SEPTIC TANK ❑ Type/Mfg I Capacity No. Compartments PKG. TREATMENT PLT. 11 +� Method�of Disposal l I 1 r a Distance to nearest: Well Foundation Property Line � r ih LEACHING LINE 1 ❑ No. & Length of lines Total lengthlsize I ! ; FILTER BED win t Distance to nearest: Well size- Foundation Property Line r SEEPAGE PITS ❑ Depth Size Number +" SUMPS LIDistance to nearest: Well Foundation Property Line'( - - t l DISPOSAL PONDS ❑ 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, a rules and regulations ofj 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,pr hick this permit is issued„I shall not employ any person in such manner as to become subject to=man's compensation laws of Califa'rnia='•Contractor's hiring or sub-contracting signature certifies the following:`1-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.' X g r The applicant must all'fo all requirecl inspections. Complete drawing on reverse side. b l r . Title: Signed X 'Date: - , FOR DEPARTMENT USE ONLY 6y Date-.�� Date u �V � �Area s a� t Application Accepted Pit or Grout Inspection'by Date Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 w ❑ Manteca 623-7104 C]-Tracy t 835-6385 Nt i.• Applicant- Return all copies to: Environmental Health Permit/Services.1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA-952011 { E F 1:FEE `" ! "'s s RECEIVED BY DATE PERMIT ND. INFO ~^AMDUNT OUE AMOUNT REAIkITTED CASH ;�4 s . „M1 ._.. .- _ + EH 13-241AEV-I/R5Y EH 14-28 •' At _ } ,•+w-tri�,.3