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l 16;i s, APPLICATION.FOR PERMIT SAN JOAQUIN.LOCAL HEALTH DISTRICT 1 1601 E. HAZELTON AVE., "STOCKTON, CA " Telephone {209} 466-6781 b PERMIT EXPIRES.1 YEAR FROM�DATE�ISSUEDr., ' ,' . �" ,; •f.�^a. 'W3 AJ P.'l ii"!. 111 ;JComplete 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 H 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 city �f Lot.Size D pry) y Owner's Name�I Phone 1 # Contractor Address ( - License No.. Phone OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑- SYSTEM REPAIR ❑ ;...'OTHER ❑ DISTANCE TO NEARE . TIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE r-FOUND AGRICULTURE WELL OTHER WELL PETS/SUMPS INTENDED USE 1. TYPE OF WELL P AREA CONSTRUCTION SPECIFICATIONS O Industrial ❑ Open Bottom ❑ Manteca a. of Well Excavation Dia. of Well Casing Q Domestic/Private ❑ Gravel Pack , ;Tracy Type o ' ❑ Public ❑Other « F Specifications ❑ Deita '`5+'� rO Depth of Grout Seal + Type of Grout ❑ Irrigation ---Approx. Depth ❑ Eastern "Surface Seal Installed by t i' Repair Work Done ❑ Type of Pump. H.P. _ state Work pone Well Destruction Q Well Diameter Sealing Material (top 50') Depth Filler Material fBefow TYPE OF SEPTIC WORK: NEW INSTALLATION D REPAIR/ADDITION ❑ DESTRU TIO (No ptic system permitted'rf public sewer is v able 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:„ j ~:Water table depth -,- SEPTIC TANK ElType/Mfg Capacity '!"`� N Compartments- "` PKG. TREATMENT PLT. ❑ '• Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines } Total length/size r=' FILTER BED Q Distance to nearest: Welt"" Foundation , ' E '� "�f"'Jj'j ,: f Property Line SEEPAGE PITS C7 Depth Size -" Number 'SUMRS ❑ Distance to nearest: T' Well Foundation *" -- 4-Property Line �« DISPOSAL PONDS Cl n 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 District.' + Home owner or licensed agent's signature certifies the following: ce ' ' "I rtify 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 comperfsation 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." T ._ f 3i The applicant ust call far all re uired ins pec . C r v q pe otpl to drawing on reverse side:: € ' Signed _ r _ -+ Title: Date: _ ", ; x - t!f FORJQEPA ENT USE ONLY I Application Accepted by # Date -�- Are's G r 4 Pit or Grout Inspection by Date Final Inspection by: Date. Additional Comments: 11 Stk 466-6781 " ❑ Lodi 369-3621. ❑ Manteca._823-7104 L1..Tracy; .8:i5 638,5 —2--- Applicant Return all copies to Environmental Health Permit/Services 1601.E..Hazelton Ave., P_.0._Box.2009, Stk..,-CA-95201-- -7:7 -- FEE AMOUNTDUE AMOUNT REMITTED C RECEIVER BY 1' ° INFO y/ GATE' PERMIT'N0. +'EH13.24,fREV.t/asl ��- �, �� - EH 1428 ✓_ O0 _ "' y