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` I A.d APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT f 1601 E. HAZEL TON AVE:, STOCKTON, CA k Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ! (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 well/pump and the Rules and Regulations of the San Joaquin Local Health District. I J I Job Address �� i/��„- City � /a_.ei_ Lot Size _'aX 11 D PM Owner's Name Address Phone 5 Contractor's Name p l.twot >,,f pcense'No. if 274 _ Phone 6 I TYPE OF WELL/PUMP: —NEW-WELL E]-- —WELL-REPLACEMENT 0 DESTRUCTION ❑ .�S} PUMP INSTALLATION-fl �'- .�� 'SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER-LINES DISPOSAL FLD. PROP. LINE �1 FOUNDATION AGRICULTURE WELL,L OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA�'-.,CONSTRUCTION'SPECIFICATIONS ' ❑ Industrial ❑ Open Bottom ❑ Manteca .4W. of Well Excavation} w Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing j4 Specifications ❑ Public ❑ Other Y, �,�.,, .-❑_Delta. Y' Depth of Grout Seal Type of Grout E] Irrigation __L__Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done 1 Well Destruction ❑ Well`%Diameter Sealing Mafeial {top 50'1 Depth Filler Material Melow,501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION V DESTRUCTION ❑ {No,septic system permitted if public sewer is / available within 200 feet.) Installation will serve: Residence .Y Commercial_ Other Number of living units: Number of bedrooms Z Character of soil to a depth of 3ffeet: C,1_,4-v P P' Water table depth SEPTIC TANK 4--)()( 15774/Mfg Capacity No. Compartments PKG. TREATMENT PLT, ❑ ` y' Method of Disposal Distance to nearest: Well Foundation Property Line j J � LEACHING LINE 4 o. & Length of lines ;Total length/size FILTER BED ❑ Distancd.,to nearest:._Well, Foundation Property Line I SEEPAGE PITS G ❑ Depth 140 _ 'Size •Z- X 1 4 Number l SUMPS W”' Distance to nearest: Well Foundation 140 Property Line DISPOSAL PONDS ❑ . 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 District. {, } 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- tion laws of California." } The applicant must call for all required in"etions:-Complete'drawing on reverse side. Signed t . -W Title:_� Date: FOR DEPARTMENT USE ONLY i Application Accepted by ----�-•- --- Date Area EJ ; `Pit or Grout inspection by Date Final Inspection by pate j Additional Comments: ❑ Stk 466-6781 ❑ Ilocli 369-3621 ❑ Manta823 104 ❑ Tracy 835 fi385--^- -----^ ""a t'�-~ �- i Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED /�CrASH RECEIVED BY rD/ATE PERMIT''NO. + EH 1324{REV.10183} t •,y1 j,� K)Irl 45 -r!/ EH 1428 �� `-' "I r u L1