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- 3 APPLICATION FOR PERMIT ys SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE,, STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) b 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. Job Address 9 �7 City "—j Lot Size PM Owner's Name Address - 1 = Phone " � - Contractor c^6 _ ddress [y!L icense.N40 V TYPE OF.WELL/PUMP: NEW WELL ❑ Phone WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ t- 'SYSTEM REPAIR ❑ DISTANCE 70 NEAREST: SEPTIC TANKOTHER C1SEWER LINES DISPOSAL FLD. ,PROP. LINE FOUNDATION AGRICULTURE WELL f OTHER WELL----L—.PITS/SUMPS ' INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS . 7f, ❑ Industrial" ❑ Open Bottom ~~ t ❑ Manteca Dia. of Well Excavation ❑ Domestic/Private: ❑ Gravel Pack Dia. of Well Casing ' ❑ Tracy Type of Casing ❑ Public ❑ Other ID Delta Specifications ._ Depth of Grout Sea! C1 Irrigation Type of Grout ----Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done Q Type of Pump H.P. I - Well Destruction LJ Well piametei State Work Done— O Sealing Material (top 50') Depth - Filler Materia! (Below 50') i TYPE OF SEPTfC WORK: NEW INSTALLATION REPAIR/ADDITION ❑; DESTRUCTION ❑ fNo septic system permitted if public sewer is Installation will serve: Residenceavailable within 2001eet.) ; Number of IryCommercial! Other living units: Number of bedrooms _ - + [' Character of soil to a depth of 3 feet: ,� .� _ � �' � (k} y SEPTIC TANK X Type/Mfg ��•, ° - "— Water table depth E PKG. TREATMENT PLT. ❑ Capacity � ' 1 No- Compartments - , ~ k _ i Distance to nearest: WellQMethod of Disposaj.= Foundation r r � Property Line LEACHING LINE No. & Length of lines F. f' Total length/size FILTER B.ED C] Distance to nearest: Well TC7 Foundation `�Ca ) ' w - 1--Property Line SEEPAGE PITS Depth :a: . f i !9 Size_ _ Number SUMPS iO Distance to nearest: Well rr��- � r` DISPOSAL PONDS ❑ w- -ei- Foundatiori r 06—>- rroperty Line.._ ? <- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, slate laws, and rules and regulations of the San Joaquin Local'Health District. Horne owner or licensed agent's signature certifies the following: ' employ any person in such manner as to become subject to workman's ompensation laws operformance' California."Contractor's work for )ch this permit is isshiring or sub cont act ng signature certifies the following:"I certify that in the performance of the work for which this permit is issued;I shall em !o J tion laws of California." _ r p y persons subject to workman's compensa- _ The applicant must call all required inspections- Complete drawing on.reverse side. Signed ,. Title: -®_. ��t�_ -9—e- -2 - t, Date: s } �F0 '�RTMENT USE ONLY Application Accepted by �Q hQ ) Date Area +l o Grout inspection by ti. J � { Dat Final Inspection by) Date Additional Comments: L7 Stk .466-$781 C1 Lodi - y X21) ❑ Manteca 823-7104 r ❑ Tracy 835- Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201] {. FEE AMOUNT DUE AMOUNT REMITTED INFO CK ; CASH RECEIVED By DATE PERMIT-N0. + EH 13-24(REV.tins) EH 14-26 l f '- tel' 2�s1�'1 "1-