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APPLICATION:FOR PERMIT SAN JOAQUIN'LOCAL"HEALTH DIS R1CT 1601 E. HAZELTON AVE, STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM, DATE!ISSUED ' rt 1 I' {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" made in compliance with San Joaquin County n - + c Local Health District. ' t"'S•V`a i tY Ordinance No.549 far sewage or No. 1862 for well/pump and the Rules and'Regulation-of he SanliJoaqn is uin ,a. Job Address .� C N a / Ado 07eA �r City Lot Size Owner's Name p ` PM + l�t3Y�j9 Address;. _ Y.a E &", k 1 Phone kpr=.OF ntractor �; i� ddress_t�4:C3oX isoWELL/PUMP: NW WELL ❑ License No.Yom $! ^Phone 11 PUMP INSTALLATION ❑ WELL.REPLACEMENT ❑ DESTRUCTION ❑ DISTANCE TO NEAREST: SEPTIC TANK SYSTEM REPAIR L7 OTHER Cl f FOUNDATION ~ SEWER LINES ` DISPOSAL FLD. ,AGRICULTURE WELL PROP. LINE FliTENDED USE OTHER WELLS-. _ PITS/SUMPS TYPE OF WELL _ PROBLEM AREA CONSTRUCTION SPE?Cl ICATIONS ❑ Industrial � a: __ ❑ Open Bottom ��-f��Maniece �'�. ❑ Do,lnestic/Private i' [Dia. of Well Excavation Dia. of Well Casing ❑ Gravel Pack ❑ Tracy TL4" ❑ Public I ype-of Casing I ❑ Other ❑ Delta Specifications ❑ Irrigation Depth of-Grout Seal ( �Appro ii Depth ❑ Eastern Surface Seal nstalled by Type of Grout Repair!Work Done ❑ ype of Pum T PUMP Well ❑ a= �l WeWellDestruction Well Diametlfr 5 '�v mark- ' - �aDane {{ Sealing Material (top 501) I ,z Depth �# Filler Material (Below 50'j TYPE OF SEPTIC ORK: NEW INSTALLATION ❑ REPAIR/A'DDI-TION"}� DESTRUCTION ❑ (No septic systerri'permitted if i public sewer is Installation will serve: Residence / available within 200 feet.► Commercial— Other�� { Number of living units: ! Number of bedrooms -7 I i" Character of soil io a depth of 3 feet:` - t SEPTIC TANK ❑ Type/Mf -Water table dopth tv PKG. TREATMENT PLT. ❑ Capacity ,. No. Compartments Distance to nearest: WeII ' Method of Disposal �Foltnilat5on Property Line LEACWING LINE No. & Length of lines S'O Total iengthLsize FILTER BED -�' ❑ Distance to nearest: Well 47' Foundation A-r Property Line SEEPAGE PITS O" Depth Size f" 4r iX' i r SUMPS Num6&. I 1ffi Distance to nearest: Well 14m" Foundation r� t e' 'Property Line DISPOSAL PONDS, EJ I"hereb'y certify that`I have prepared this application and that the work will be done in accordance with San tiJoaquirrcou�ty ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. Home owner or Iicensed agent's signature certifies the following: `r.' 6 E 1. em to an f f 9 "I certify that in the performance of the wo'k.for which this permit is issued, I shall not P Y y person in such manner as to become subject to workman's compensation laws of California.".Cont�acior's hiring,or sub-contracting signature certifies the following:"I certify that in the performance of the work for which t tion laws of California." his permit is issued, I shall employ persons subject to workman's compensa-_"' The ap�plican must call for all required inspections. Complete drawing on reverse side. 1 Signed: d r Title: Date: OR DEPARTMENT USE ONLY Application Accepted by .� �, `- ft Date ea- Pit or Grout;fhspection by Date Final Insp ce tion by 4 Y _. r] / t Date 6 Additi nal Comments: �~ ❑ Stk 466-6781 ❑ L i 3 110 Manteca--823-7104 ❑ Tracy 835-63g5r j Applicant- Return all copies to: Environmental HealtFi" ermit/Services 1601 E. Hazeltori'Ave., P.O. Box 2009, Sik., CA 95201 FEE AMOUNT DUE AMOUNT REM_ITTEW_ CK INFOI k_. CASH RECEIVED BY DATE PfRMIY`NO. EH 13-24(REV.4/8 5) EH 1428 ..+�> /� ... ` -71<_-i + i.