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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT ? 1601 E. HAZE;_TON AVE_ STOCKTON, CAS ' I Telephone (209) 466-6781 PERMIT EXPIRES TYEAR ROM DATE ISSUED I l (Complete in Triplicate) I 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 Rules and Regulations of the San Joaquin ) Local Health District. 4 Job Address f.-- �— _City Lot Size PMS _ Owner's Name /rT h - __ Address J 6 Phone Contractor. E 5 7== � �= Address C J u License 4 TYPE OF WELL PUMP? NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ s PUMP INSTALLATION 0�- SYSTEM REPAIR ❑ OTHER ❑ DISTANCE,.TO.NEAREST_.SEP._TIC..TANK- SEWER LINES.,— DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing tj omestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications 1-1 Public CI Other CI Delta Depth of Grout Seal Type of Grout _ 1 l I I Irrigation -Approx. Depth I 1 Eastern Surface Seal installed by \ 1 I Repair Work Done El Type of Pump H.P. ( State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') G � � I Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION Ia REPAIR/ADDITION I I DESTRUCTION ( I Wo septic system permitted if public sewer is t' `�++¢ available within 200 feet.] Installation will serve: Residence Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water.table deptha t SEPTIC TANK ❑ Type/Mfg -,Capacity Fs+ N CR�om f�a�rptments^� Ix PKG. TREATMENT PLT. ❑ ., rti..r M k�0*0 y Distance to nearest: Well Foundation Propert h LEACHING LINE ❑ No. & Length of lines ' Total length/size�tL FILTER BED ❑ Distance to nearest: Well Foundation Pro f- UIN COUNTY , PIS LAI- HL 7 1-? 7f ...�-., SEEPAGE PITSI I Depth Number } 1 y/ +- SUIUIPS.._.. L7 Distance to nearest. . Well F ndatron P-roperty.Line ��r`�`„'—�:��•-,.,_��.:...�,----�'�'----�--"---'---� f—�.-a�-;-�+�+�..—.--�' ,Qe:�.R-.� �--- `•-�=_�--f----sus - .. -_ _ � -- 'DISPOSAL PONDS ❑ i y 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§ttict:, / Home owner or licensed agent's signature certifies the fallowing: '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- tion laws of California." The applica t Zmustcall for all required inspections. Complete drawing on reverse side. Signed X Title: Date: �- FOR DEPARTMENT USE NLY y-37-a Z Application Accepted by Date Area Pit or Grout Inspection by //Data Final Inspection by �� / //J1- ate �� ' I Additional Comments: 4 ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 200, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK 4 CASH EIVED Y D E PERMIT'NO. INFO /?+,/ y�c/ It ♦.EH 73211REV.t/H51 TL y rg� ! 'P �r V_-, EH 14-28 C KKV✓JJ 3''n