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k APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT I 1601 E. HAZELTON AVE., STOCKTON, CA Telephohe (209) 466-67$1 PERMIT EXPIRES TYEAR FROM DATE ISSUED v f (Complete in Triplicate APfz!?cation is herey made to the San Joaquin Local Health bt and/or install the work herein described. This application 7s lh District for a permit to construc in compliant 'At San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Bre iih Dist r t'. . "e r City_ Lot Size �_ PM ,�.��rr.s �Dbi4ddres3. . �f 111 :3. # � *one k r,�°Ow7rser's l• Address Na r V'Z Z�Phone—. &S S Ips ss { Address License No. ? �i Contract �' NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ I £ ,TYPE OF WELLIPUMP PUMP INSTALLATION .13SYSTEM REPAIR' O OTHER IJ l DI$TNCE TO NEARE57 ,SFPTIC.TANK SEWER LINES DISPOSAL FLD. PROP. LINE } 4K'1U 1pAT1O,N AGRICULTURE WELL OTHER WELL PITS/SUMPS � 4INTENDED USf r' A -TYPE OF WELL• PROBLEM AREA CONSTRUCTION SPECIFICATIONS l j ' •_ pia. of Well Casing i Industrial ,°:a!' . ❑ Gpeh"Boitom ❑ Manteca Dia. of 1NeH Excavation g —Type of Casm"""'""'�' Specifications ❑ DomestiElrPrivate ❑ Gravel Pack ❑ Tracy yp g kzType of Grout—_— .1s f'1 Public n Other , C1 Delta Depth of Grout Seal I i Irrigation Approx. Depth i I Eastern Surface Seal Installed by f Repair Work Done ❑ Type of Pump H.P. Siete Work Done Weil Destruction ❑ Well Diameter Sealing Material atop 50') " Filler Material IBelow'50'lt'� Depth ''r~;.� •r` -' 1 TYPE OF SEPTIC WORK: NEW —INSTALLATION..1. REPAIR7 4DDI�,ION l ) DESTRUCTION l 1 INo"septic system permitted if public sewer is ..rs ^�. •"ailable within 200 feet.) ' Installation will serve: R?'dence Commercial` Othee -t Number of living units: ` Number edroo s ` -) F Character of'soil to a depth of 3 feet: d Water table depth SEPTIC TANK Type/Mfg, Capacity �� No. Compartments " F ..� Method of Disposal' PKG. TREATMENT PLT, d % r'" C;.`T r ,a �? c ,' -- Distance to nearest: Wd�s -e.�_ Foundatioh �� Property Line, e or F ' t ? LEACHING LINE 9;-No. & Length of lines — �ota!_Iength/size lay. FILTER BED Cl "Distance to nearest: Well Foundation_:-,_..!l� Property Line y r) SEEPAGE PITS, I�Depth "`` Size Number i SUMPS Cl Distance to nearest: "' Well Foundation Property Line l n _ �. DISPOSAL PONDS ❑ .i 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 rules and regulations of the San Joaquin Local Health Di?;trict. 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 which this permit is issued, I shall employ persons subject to workman's compensa- r tion laws of California." The app:7��FalWinspections. Complete drawing on verse 'de. . Signed Title: Date'L?JL( FOR DEPARTMENT USE ONLY i A{iplication Accepted by Date�' Asea or�Grout Inspection by ate ' Final inspection by Date -L7 S: ditional Comments: b Y'tk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 17.Tracy 835-6385 'A licant - Return all copies to: Environmental Health Permit/Services 1601 E. HazeltoCK n Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED SH RECEIVED BY DATE PERMIT'NO. INFO + EH 13241 .,i>j57' .�Q - �/k �$4 . EN 446