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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE.i ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1'YEAR FROM DATE ISSUED (Complete in Triplicate) application is Application is hereby made to the San Joa + quin Local Health District for a permit to construct and/or install the work herein described.This app` made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for welllpump and the Rules and Regulations t �=off quip Local Health District. Lot Size PM City p Job Address it 1 11 _ Phone (fy Address Owner's Name � S � Phone 2" =AdHress"��;�h��•-ai�-�•��License No:� ContractarDESTRUCTION IJ E F WELL/PUMP: TYPE ONEW WELL,�7 WELL REPLACEMENT ❑ r SYSTEM REPAIR ❑ OTHER ❑ I I PUMP INSTALLATION_ f .`PROP. LINE z7 1 , SEWER LINES _ = DISPOSAL FLD. DISTANCE TO NEAREST: SEPTIC TANK y--- -----�- AGRICULTURE WELL �� QTHER WELL "-� PITSISUMPS _ FOUNDATION. - ' INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS _ 5 .L Dia. of 11Vell'trasing 'G2`Industnal "• ❑ Open Bottom, O [shanteca ;. ~ f^Well Excavation' �� Specifications s 4.W-, �s..` Type of Casing .. k �Domestie�Privete; " ravel Pack - Tracy- r Type of Grout_. ` ' P Delta t-Depth of Grout Seal Y Iq� i f`l Public Cl OTiher } ,e � L•elJg7��ie'�1�`_ \-Z70-Approx. Depth I I Eastern 5rlrface Seal Installed by I Irrigation . ��g� H P ,5tatelWork Done — 1 ,:T a of Pump + -' r Repair Work Done �'❑ � S A ti - 'Sealing Material (top 50'i Weil Destruction ❑ 'Welll3iameter =r Depth". Filler Material (Below 50'1 p YPE OF SEPTIC WORK: NEW INSTALLATION I S` REPAIRIADQITidN 1,I DESTRUCTION t i availableseptic within 200 system feetltl,d�f public sewer is Installation will se idence! Commercial Other Number o1 living units: bedrooms r r Water table-depth \ Character'of-soil to,a-depth of-3--feet: y -', Capacity No. Compartment's `A SEPTIC TANK ❑ Type/Mfg ; Method of Disposal PKG. TREATMENT.PLT. ❑ �' t I �T R �i Foundation Property Line Distance to nearel;t:� - Well l _ Total length/size i LEACHING LINE L No. & Length of lines Fdundatian Property Line FILTER BED( O Distance to nearest: w Well, _ ., e - $1Z9 ci- NumbBr ti SEEPAGE PITS I l Depth. Property Line SUMPS ❑ Foundation Distance to nearest: Well ..- x A DISPOSAL,�ONDS ❑ J 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 Locale Health DietricL; "•' '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 signature shall not employ any person in such manner as to become subject to workman's compensation laws of California." Contraceosonhiring subject to workm n,'sgompensa- certifies the following: "I certify that in the performance of the work for which this permit is issued,k shall employ p 1 tion laws of California." The applicant Ire ctions. Complete drawing on re r I pill Title: f Date: Signed X FOR DEPARTMENT'USE ONLY r w ♦ f � Date Area I xApplication Accepted by i ; Final Inspection by Date � Pit or Grout Inspection by Data !�• f Additional Comments: ❑ Still 466-6781 0 Lo F 369-3621 0 Manteca 823-7104 � Tracy 835 6385 r }Applicant- Return all copies to: Environmental Health Per 1601 E. Hazelton Ava., P.O. Sox 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CASH 4 RECEIVED BY DATE PERMIT N0/ INFO l s EH 13-24-(REV.5/e 5) .,. - i EH 14.26 _ - _