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r APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT I 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1'YEAR FROM DATE, ISSUED (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 described. This application is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 186 well/pump and the Rules and Regulations of the San Joaquin Local Health District. � Job Address �o I Lot Size PM Owner's Name i/d _ --- Address r n .�f � � � - Phone 13 — 11 kEa { Contracto AddfessA ! O License NoAI29 2LG Phone- �g IU• — TYPE OF WELL/PUMP: NEW WELL El `WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ f -� ' SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK .SEWER LINES DISPOSAL FLD. PROP. LINE 9 FOUNDATION TAGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE---- -TYPE OF WELL PRQBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial .❑ Open Bottom ❑ Manteca Dia, of Well Excavation Dia. of Well Casing t1, ❑ Domestic/Private. ❑ Gravel Pack C7 Tracy Type of Casing Specifications €'1 Public 1`7 Other Cl Delta Depth of Grout Seal Type of Grout I I Irrigation t _Approx. Depth € I Eastern Surface Seal Installed by Repair Work Dories❑_ Type bf Pump H.P. State Work Done Well Destruction ° ❑ Well.Diameter I Sealing Material Itop 50') Depth er Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 RCr'?iR ADDITION DESTRUCTION l I (No septic system permitted if public sewer is t` available within 200 feet.) Installation will serve: AResidence X Commercial Other Number of living units: �� Number ofvgedrooms r +� Character of soil to a depth of 3 feet: _ Water table depth V0 , SEPTIC TANK ❑ Type/Mfg<n(A�ra 14� Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line_ b 11 a i LEACHING LINE `� l p No. & Length of lines Q� F "'1O dotal length/size �,� FILTER BED ❑ Distance to nearest: Well 55-6— Foundation_ `� Property Line SEEPAGE PITS l I Depth Size _ Number SUMPS U1 Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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, and i rules and regulations of the San Joaquin Local Health Diltrict. 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"fdllowing: "I 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." The applicant ��tll r as req u'ed inspections. omplete drawing on reverse sid ` Signed X Title; U. t•r Date: FORD PARTMENT USE ONLY - Application Accepted byl�� Date_,2��%/' Area Pit or Grout Inspection by Date Final Inspection by Data Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 0 Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 it FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. INFO CASH +,EH13.244REV.F/H5f �� !+_Q 14 1 EH 14-26 t'�