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APPLICATION FOR PERMIT SAN JOAQUIN, LOCAL HEALTH DISTRICT ! 1601 E. HAZE T ON AVE., STOCKTON, CA s - Telephone-(209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED i (Complete in.Triplicate) Application is hereby made toithe 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 d Local Health District. k City "1. cy - Lot Size- PM Job Address ii' SV Ower's dame � AddressPhone ' Contracto LU 4a Address License No. $1lLr�.—Phon TYPE OF WELL/PUMP: 1� NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑, SYSTEM.REPAIR ❑ c• OTHER ❑ v!j DISTANCE TO NEAREST: SEPTIC TANK ' SEWER LINES__, DISPOS;4L^FLD7 -� PROP. LINE t �� FOUNDAT101V A 01 GRICULTURE WELL. OTHER WELL PITS/SUMP51 ! kExcavation! - INTENDED USE �7YPE OF WELL 4 PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial t_ Open Bottom ❑ Manteca Dia: of Well Excavation 1' Dia. of Well Casing f ,,:� t __—; s t.. ,.�_i Specifications ❑ Domestic/Private ❑ Gravel'Pack ❑ Tiacy Type of Casing .l k ❑ Public !C] Other '" 11Delta " Depth of Grout Seal [ Type of Grout ❑ Irrigation �pprox. Depth ❑ Eastern d,Surface Seak installed by ' '' f State Work Done ` Repair Work Done ❑ Type of Pump H P i4. t RSealin Material Ito 50?> I Well Destruction El Well Diameter.. 4' 9'. p Depth ~ ' Filter Material`(Below,21) `_TYPE OF SEPTIC WORK: NEW INSTAI-IAT#N ❑ .'REPAIR/ADDITION V DESTRUCTION❑ (No septic system permitted if public sewer is available within 200 feet.) +, Installation will serve: Residence I_L . COmmercia!''_.4Otther I�r Nuber of bedrooms r Number of living units: m ,_ /] Character of soil to:a depth_of 3 feet: L'' Water table depth pf _ r 6 SEPTIC TANK M Cl! Type /Mfg capacity- No. Compartments j .A j jF Method of Disposal 1 PKG'TREATMENT PUT. ❑ t r Distance to nearest: Well r Foundation Property Line e; LEACHINGjLINE '{ ' cNti'& Length of lines -- Of1•/ Total length/size 4 FILTER BED 17Distance to=nearest:, Well IzI61 ` Foundation -N- Property Line 2&2' A- `: Number SEEPAGE PITS ❑h' Depth s Size SUMPS �k Distance to nearest: Well Foundation _ Property Line DISPOSAL PONDS ❑ � IThe�eby certify that I have prepared this application and that,the_work will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of they San Joaquin Local Health District. i •- Home owner or 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 employ any person in such'manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work'for whlcfi this permit is issued,I shall employ persons subject to wo kman' ompensa tion laws of.California." II! E j The applican must call fo.all required inspections. Complete drawing on reverse side. t # Date: Signed Tills: FOR DEPARTMENT USE ONLY �} a " i Application Accepted by .IkA Date b'4 ^ Area it Grout Inspection byl ate 1 — Final Inspection b ate Adoitional Comments: d Stk 466-6781 Qltodl 369-3621 ❑ Manteca 823-7104 ❑ Tracy 83563115 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 + FEE I' AMOUNT REMITTED RECEIVED BY DATE PERMIT'NO. INFO AMOUNT DUE SH +'EH 13-24 ?101(! �V rJ r . EH 1428 I .