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E . 3 APPLICATION FOR PERMIT i SAN JOAQUIN LOCAL-HEALTH DISTRICT _ 1601 E. HAZELTON ON AVE., STOCKTON, CA Telephone (209) 466-6781 ` PERMIT EXPIRES 1-YEAR FROM DATE ISSUED {;r° (Complete in Triplicate) Application is he'eby 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 tha Rules and Regulations of the San Joaquin Local Health District r J. -tic • =Y `.` - C3 <-r 2-0 -a y JobAddress., r ; City " Lat Size PM Owners Name 3` Address Phone I= » Contractor i Address, Phone 7 .�'"'oCf!>p " STYPE 41 OF WELL/PUMP:* :'i License No. A' NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION El 1" Pt1MP INSTALLATION ❑ 1 a " , SYSTEM REPAIR p:.. OTHER q DISTANCE TO NEAREST SEPTIC TANK ¢ SEWER LINES i 1' DISPOSAL FLO. PROP.LINE p. FOUNDATIONS AGRICULTURE WELL " OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL „PROBLEM AREA .,CONSTRUCTION SPECIFICATIONS ,w a0 industrial 1 ❑,Open Bottom ;.❑ Manteca Dia. of Wel[ Excavation Dia, of Well Casing' ❑ pomestic/Private ❑'Gravel Pack ❑ Tracy ;Type of Casing 1 .. J71 Public t Cl Dther Specifications fl Delta Depth of Grout Seal Type of Grout I.i Irrigation ` Approx'. Depth . I I-Eastern Surface Saul Installed byv Repair Work Done ❑ "Type of Pump H,P. State Work Done _ Well t]estrucuon ❑ [ Well Diarnerer� Sealing Materia! (top 50'1 r Depth, :Filler Material ieelow 50) s : TYPE OF SEPTIC WORK: NEW INSTALLATION 1 7 REPAIR/ADDITION l 1 DESTRUCTION [ I (No septic system permitted it public sewer is - Insia: available within 200 feet.) llation will serve Residence a Commercial Other { Number of living units: 9 Number of droom 3 ` t ` Character of-soil to a depth;of•3 teat:' + s SEPTIC TANK 'N Type/Mfg;. 3 o- Water table depth }PKG TREATMENT PLT: ❑ n ;, Capacity No. Compartments [ I� X40 Method of Dis osal Distant near t:Y Fol ation p a+r' well _ Property , p Y Line a # i LEACHING LINE ❑1 No: & Length of linesw �'FILFER BED Total length/size ❑ Distancwto nearest: ,Well Foundation„ t „ , 3 Property Line s + j SEEPAGE PITS'; Depth t i I I Side sSUMPS Number ? 0 'Distance to nearest., Well Foundation DISPOSAL PONDS O t' Property Line Y i fi rr I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin caunty ordinances, state laws, and j w rules and regulations of the,San..Joaqujn'Local Health'Di1trict; `Home owner or licensed agent's signature certifies the following: "E certify that in the performance of the work for which this permit is issued,'I shall not r{F 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 which this permit is issued,1 shall employ persons subject to workman's co. - alon laNirs of,Califomia The"applicant st Ga1I for all re uirad nspections. Corflplete drawing on Yey se side. ! Signed x Title: / r Date: - � FOR DEPARTMENT,USE ONLY Application Accepted by f„ i Ar r Date Area l� ' I v Pit or Grout Inspection by y ' - 0 . # Date Final Inspection by Additional Commen't's w r _ ate l! If ❑-Stk,- 466-6781.. Q Lldi. .369-3621. IJ Manteca 823-7104 q Tracy, 8356385 Applicant Return all copies to Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 85201 } i T FEE AMOUNT DUE AMOUNT REMITTED, CK 1 INFO CASH RECEIVED BY DATE PERMIT'NO, i EH M24 IRM'il a 51 'EL 14-29