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APPLICATION:FOR PERMIT .. . . ... .. . SAN JOAQUIN LOCAL HEALTH DISTRICT ' 1601 E. HAZEL ION AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED .:{Complete in:Triplicate} t.. , .. - Application is hereby made to the San'Joagwn Local Health District fora permit to construct and/or install the work harem described.TNs application is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for welllpump and the Rules and Regulations of the San Joaquin Local Health District.. .. ,11. rt pa` , , .'. "'d !City of Size ' PM- Job Address `I .�G 44+r Owner's Name _ ,�' � _ Ad- -0 Phone License No. a ` � Phone Contractor's Name TYPE OF WELL/PUMP: NMN WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ r SYSTEM REPAIR ❑ OTHER ❑ pISPOSAL FLS.° - PROP. LINE DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES n _ FOUNDATION : ° AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing 37 4 ❑ Industrial 171 Open Bottom ❑ Manteca s Dia.-of Well Excavation Type of Casing Specifications W ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Typ '� _ Type of Grout 1-1Public 17 Other El Delta Depth of Grout Seal ` 0 ❑ Irrigation - --Approx. Depth ❑ Eastern' Surface Seal Installed by Repair Work Done [I Type p State Work Done Type of Pump _�_ _ . Wel! Destruction El Well Diameter Sealing Material (top 50'1 Depth Filler Material (Below 501 f DESTRUCTION ❑ IND septic system permitted if public sewer is' Y PE OF SEPTIC WORK:. NEW.INSTALLATION REPAIR/ADDITION ❑ DE available within 200 feet.] TY , t I Installation will serve: Residence Camme ial AOOOther t Number of living units: Z. Number of edrooms 4 Water table depth Character of soil to a depth of 3 feet: No. Compartments "°""" SEPTIC TANK ❑ Type/Mfg. Capacity ,. Method of Disposal � PKG. TREATMENT PLT. ❑ Y Distance to nearest: Well �Foundation Property Line - J LEACHING LINE ❑ No. & Length of lines Total length/size � }} FILTER'BED ❑ Distance to nearest: We11 Foundation � Property Line Number SEEPAGE I SEEPAGE PITS ❑ Depth Size SUMPS ❑ Distance to nearest: Well "" Foundation Property Line DISPOSAL PONDS- ❑ hereby certify that l 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. Home owner or licensed agent's signature certifies the following: , certify that in the performance of the work for which this permit is issued, I shall not mpensation laws of California."Contractors hiring sub contracting signature employ any person in such manner as to become subject to workman's coich this permit is issued,I shall employ persons subject.to workman's compensa certifies the following: "I certify that in the performance of the work for wh tion laws of California." The applica ust all for a I required inspections. Complete drawing on reverse side. F: _ Title: Date: Signed FOR DEPARTMENT USE ONLY f 1 Date lL Area Application Accepted by Date Y Date Final Inspection by } Pit or Grout Inspection by Additional Comments: ❑ Tracy 835-6385 r❑ 5tk 466-6781 - ❑ Lodi 369-3621 ❑ Manteca 823-7104 -` Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 Applicant- Return all copies to: Environmental Health FEE AMOUNT DUE AMOUNT REMITTED CY RECEIVED BY DATE PERMIT"NO. Y `'7 '1 + EH 13-24(REV.10/83) INFO ^-��• p o '�� — ` .- EH 14-26