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R = .r APPLICATION.FOR PERMIT -" SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL TON AVE.,,.STOCKTON, CA Telephone (209) 466-6781 , PERMIT EXPIRES 1 YEAR'FROM DATE ISSUED r . ,,_.,.(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. 1862 for and the Ruies.-and Regulations of the San Joaquin Local Health District. Job Address Y5 �" '" ��r 1�� 4ity Lot Size'_ '- Owner's Name e ddress 5(�3 0 Phone T w Contractor Address License No. Phone TYPE OF WELL/PUMP: NEW WELL El WELL REPLACEMENT ❑ _ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM.,REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES A DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 'r O'Industrial LD Open Bottom-Q—Manteca Dia- of Well Excavation t Dial of Well Casing ❑'Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑'Irrigation �Approx. Deptii' ❑Eastern Surface Seal Installed by t Repair Work Done ED Type of Pulp,z ` H.P. State Work Done_t ' Well Destruction ❑ Well Diameter.. -=�'� �Sealin"g Material (top 501 Depthxt.Filler{Materiai'(Below 50'1 TYPE OF SEPTIC WORK: NEW INSTALLATION ,REPAIR/ADDITION ❑ DESTRUCTION ❑ iNo septi6.system permitted if public sewer is + y Y .` .available within 200 feet:] 15 :Installation will serve: Residence Commercial Number of living units: Number of bedrooms ,,, { g �, w i f -Character of soil to a depth of 3 feet -� * "t Water table depth`F SEPTIC TANK ❑ Type lMfg Capacity , Q No`Compartment PKG. TREATMENT R T.,3- -� -r'Meihod of DispdsalQAAEA#6i �Di�stance to nearest:F. Well!_S Foundation 14 Property Line LEACHING LINE 9 ❑i No- & L ngth of lines -$ Total length/size FILTER-BED. ❑ Distance to nearest: Well_f�'�d Foundation .Property Line F CJ n�f /.-f a f" a .- `. SEEPAGE PITS ❑ _'Depth ��'�_ Size ,�4F 'Number Ia y. SUMPS ,,,�0'� Distance to nearest: Well foundation �421 Property Line DISPOSAL PONDS -)e ❑ f I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county-rordinances, state laws, and rules and regulations of the San Joaquin Local Health District. T .01, Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which 16`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 subcontracting 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." :. The appli call for all r inspections: Compel te_drawing on reverse side.I�N ' Signed Title: Date: FOR DEPARTMENT USE ONLY Application Accepted byby _Date r Area 1 Pit or Grout Inspection by Date 1� ." Final In action b - Da, (ter 2- Additional Comments: - 1 ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7144 C7 Tracy 835-6385 �. Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O.'Box'2009, Stk., CA 95201 f FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY 'DATE PERMIT'NO. _ INFO CASH 7 + EH 13-24'IREV,I/x 51 EH 1426 - r