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APPLXATION_FOR'PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT. 1601 E. HAZELTON ON AVE., STOCKTON, CA Telephone (209) 466-57$1 PERMIT EXPIRES 1 YEAR FROM DATE 'ISSUED (Complete in Triplicate) �' '* ° � r 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. 1862 for well/pump and the Ryles and Regulations of the San Joaquin -!Local'Health District. Job Address ! �. r: 4 -� I•.. City 'Lot Size PM 46 Owner's Narlie ddress -Phone M > �j Contractor ./ AAddress License No. -S- Phone 41 J TYPE OF1,VVtLL/PUMP: NEW-WELL 111 WELL LJ DESTRUCTION El PUMP INSTALLATION ❑ f, �I JSYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANKvSEWEE LINES DISPOSAL FLD. POOP. LINE i FOUNDATION -k- '`,"rAGRICULT;URE WELL OTHER WELL PITS/SUMPS —INTENDED-USES TYPE OF WELL PROBLEM A'REA�"'CO STRUCTION SPECIFICATIONS "� ❑ Industrial >Open Bdttom�, ❑ Manteca Dia:of Well Excavation Dia of WeII Casing ❑ Do estic/Private - ❑-Gravef Pak I- Tracy Oe-of-Gasing -Specfic tons T- ❑ Pcib-ic r E' ❑ Other 1 ❑ Delta 1 Depth of Grout Seal Type of Grout ❑ Irrigaiion� ; t._Approz. Depth 1-1EasternSurface Seal Installed by Repair]Work Dome ❑ Tqp of Pump "�`" " H.P. State Work done Well:Destrtic ion 0 Well Diameter =Sealing Material {top 50') I 1j V �i f Depth Filler Material(Below 50'1 TYPE OF SEPTIC WORK: -NEW-iNSTA'LLATION ❑ REPAWADDITION)r, DESTRUCTION ❑ fNo septic system permitted if public sewer is ;v< ..- � available within 200 feet.) n will serve: InstallatioResidence T°'--` _ 4 Commercial-�.,-j Number of livingunits: r � Number of b rooms Character of sail to a depth of 3 feet: — 1 _Water table depth Q SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments' PKG. TREATMENT PLT. ❑ Method of Disposal (� Distance=o nearest: WeII Foundation Property Line ` 3 LEACHING LINE f No. & Length of fines r Total length/size X 2, ` FILTER BED ❑ Distance to nearest: Well! Foundation_/d f+ Property Line .,, ' SEEPAGE PITS' ; Depth ��, Size# �r Number �` MPS 1 * P SU � ❑ Distance, Wella/fid T'f" Foundation- �D r'-,F�- Property Line Y. DISPOSAL PONDS �^ ❑ 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' rules and regulations of the San Joaquin Local Health District. \ 1— Home owner or licensed agent's signature certifies the following: "1 certify that in the performance of the\vhbrk-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 which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." r h The applicant must call for Il.requ~ dinspections. Complete drawing on reverse side. .X I Signed Title: r Date:± t� FOR DEPARTMENT USE ONLY p Application Accepted by Date O Sr~ Area \ji© Pit-or Grout Inspection by _ Rafe Final Inspection by Date r r Additional Comments: - ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 1 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., PA,'Box 2009, Stk., CA 95201 FEE INFO AMOUNT.DUE AMOUNT REMITTED CA H RECEIVED BY; DATE PERMIT NO. t fi + EH 13.24 TREY.V a 57 '-• - �r'�"!�'^--'�-� .�^----^^---^—'• EH 1426 � `U !J � ¢ �"? 'L _ --"._.. ,, . Lo es - 5 -� a