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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT Q 1601 E. HAZELTON AVE.,s STOCKTON, CA r" ✓" Tele phone (209) 466-6781" PERMIT EXPIRES 1-YEAR FROM" DATE ISSUED (Cornplete 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. t&12 FJIM Job Address / 014 City at"Size " G4 3.." i» =av (J rl .0— ;PhoneOwner's Name ' ddress Addresses` License Phone :, - Contractor — TYPE OF WELL/PUMP: NM WELL gr JWELL REPLACEMENTj❑ DESTRUCTION 11PUMP INSTALLATION L�' SYSTEM REPAIR'.E] J. . OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK --sem®� SEWER LINES �49 + f DISPOSAL FL'D1 . �` PROP. LINE d FOUNDATION AGRICULTURE WELL�� OTHER WELL ��p'I� PITS/SUMPSI�U Q INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS -iv "U4� ❑ //JC Industrial ❑ Open Bottom Manteca Dia. of Well Excavation ' �Dia. of-Well Casing omestic/Private �6ravel Pack i ❑ Tracy Type of Casing_.. s y Spec' cations ,. ,' 7 Public Other f :4 ❑ Delta Depth of Grout Seal Type of Grout Pf ❑ Irrigation ---Approx. Depth 4',❑ Easters Surface Seal Installed byC 1'-ri,iA Repair Work Done d Type of Pump `vF+Y. State Work Done Well Destruction ❑ Well Diameter Sealing Material 4top 50') Depth W" Filler Material {Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION d�REPAIR/ADDITION ❑ DESTRUCTION ❑ INo septic system permitted if public sewer is available within 200 feet.) t Installation will serve: Residence Commercial Other� $`Number of living units: 3 Numbbr`of bedrooms I j Character of soil to a depth of 3 feet: ! '`A `gip Water table depth SEPTIC 'r ❑ Type/Mfg) Capacity r No. Compartments. t PKG.-TREATMENT PLT. Elrk... ' � f.t a Method of Disposal �,..�`: � ,� Distance to nearest: Well Foundation Property Line. ff t } , LEACHING LINE ❑ No.k Lengthof leins ` Total len th/size FILTER BED 11Distance to nearest: Well S Foundation Property Line SEEPAGE PITS - LJDepth Slze s " r Number SUMPS ❑ Distance to nearest: Well Foundation t Property Line f iDISPOSAL PONDS -4p I Lhereby certify that I have'prepardd 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 shat! not employ any person in such manner as.to become subject to woikman's compensation laws of California."Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work which this permit is issued, i shall employ persons subject to workman's compensa- tion laws of California." t The applicant ust ca for)1 q d inspections. Complete on reverse si f c Date: S U S Signed tle: OR tTMIE T USE ONLY I Application Accepted by.1 r Date V Area t -- j t Date I Pit or Grout Ins pecI j Date Final Inspection by , e tT r f i Additional Comments;- ti 0 Stk 46B-87B14_) �❑•Lodi} 369 Manteca 823-7104 Tracy 835-6385 Applicant- Return all-copiesAo: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.Q. Bax 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK CASH RECEIVED BY DATE PERMIT`NO. .INFO + EH 13-24(REV.1/5 5 tL EH 1426 —g.