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APPLICATION FOR PERMIT SAN JOAQUiN LOCAL#HEALTH DISTRICT 1601 E. HAZE I-ON AVE., STOCKTON, CA Telephone (209) '466-676i " PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete In Tfiplicate) Application is hereby made to the San Joaquin Local Health District for x y ` made in compliance with San Joaquin County Ordinance No. permit to'construct and/or install the work herein`described. This application is Local Health District. ,. 549 for sewage or No."71862 for well/pump and the Ryles and Regulations of the San Joaquin i Job Address - � �x I'J / qi t� (�' Lot Size 3,01f1#_PS. PM + a Owner's Name �/j'l fy�y I Address Phone p�3`/ 7 ConActor C! ;?7 �!.•Address'-TYPE(]F _L/ P: k License No. NEW WELL [I •� WELL REPLACEMENTPhone ❑ r� PUMP INSTALLALD TIDN DESTRUCTION _ ❑ DISTANCE TO NEAREST: SEPTIC TANK SYSTEM REPAIR ❑ OTHER ❑ SEWER LINES DISPOSAL FLD. FOUNDATION.�"AGRICULTURE WELL PROP. LINE , INTENDED USE - OTHER WELL TYPE OF�WELL "PROBLEM AREA _ PITS/SUMPS ❑ Industria! ��._.. CONSTRUCTION SPECIFICATIONS ❑ Open Bottom ❑.Manteca Dia. of Well Excavation ❑ Domestic'/Private ❑ Gravel Pack Dia. of Well Casing ❑ Public ,' ❑ Tracy Type of Casing Specifications Other p pelta. " "' ❑ Irrigation:: _N Depth of.Grout Seal " prox. Depth Eastern Surface Seal installed by yvz Type of Grout RepairWork Done ❑ Type df Pump R Well Destruction H P. State Work Don t } s �_�_ ❑ Nietl Diameter... t Sealing Material (top 50') _ � � Depth.""". r•;,,_. ... '7 TYPEF"SEPTIC;WORK; f11EW�lNSTALLATION Filler Material !Below 5011 j " , REPAIR/ADDITION ❑ DESTRUCTION L7 (No septic system permitted if public sewer is r P= t 3r "+`�✓' "` available within 200 feet.) Installation vtiil serve: Residence Number e , � � .Commercial Other 0 Number of livin units:"� •-"�- °" g Number, f edro mss=.� Cha racter.of soil-to a depth of.-3 feetPA SEPTIC:TANKg Type/Mfg__' " s Water table depth v PKG.TREATMENT PLT. p;. ` I Capacity_ No. Compartments 1 Distance to'.oearest:, Well Method of;%Disposal - S - Foundation Property Line LEACHING LINE,", '+ — _ +'` Na: & Length of li ®' _ r' FILTER-BED` �V ❑ fpi ance_fo.nearest Well IS Total length/size ,,,.._ .. FoundationtA f9 r (1 Property Line SEEP GE PITS1 ❑ " Depth _ . \ SUMPS Size _ ❑ Distance to nearest: O DISPOSAL PONDS R� Well�., Foundation _ ❑ Property Line�� " I hereby certify t"Jin have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, an rules and regulatiorts of the San Joaquin Local Health District, Home owner or-licensed,hgent's signature certifies the followintheg: d i employ any person in `such manner as to become subject to workman's oomtpensat on lawsoof Caiifonce�niahe Contractor's work for whichthis oPsub contracenglsignashall turnot e 0--, certifiesthe following."I certify that in the performance of the work for which this tion laws of California." permit is issued, !shall employ persons subject to workman's compensa- The applicant must call for all required inspections. Complete drawing on reverse side. ' Signed Date: FOR DEPARTMENT USE ONLY � Application Accepted by � a, Date Sr Grout'inspection by � � . Date Area _ Final Inspection byfW r Additional Comments: Date ❑ Stk 466-6781 - ' ❑ Lodi 369-3621 ❑ Manteca 823 7104 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E.❑Haze!on Tracy 835-6386 fAve., P.O. Box 2009, Stk., CA 95201 a FEE AMOUNT DUE F + INFO AMOUNT REMITTED RECEIVED BY H DATE" PERMIT`N0. d +EH 14- EN t EH 1426 � �7 1_5�KgS Ss —13 a9