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Y APPLICATION FOR PERMIT SAN JOAQUIN'LOCAL HEALTH DISTRICT T ON AVE., STOCKTON, CA 1601 E. HAZEL --Telephone (209) 466-6781 PERMIT EXPIRES 1.YEAR FROM DATE ISSUED x 42, ti ... ., ,!. (Complete in Triplicate) r 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 JoaquimCounty Ordinance No.549 for-sewage. No.•1862 for well/pump and the`Rul and Regulations of the San Joaquin Health District. .r . :r ._, } -�� Local He ". .. . � .. ,"� t. J _ - CityC Lot"Size PM Job Address /'' AM'�+ 1 . t Address O Phone Owner's Name - �' Contractor Address 22J2 q G.- • a f_ License No. +� Phone'/ TYPE OF WELL/PUMP: _NEW WELL. ❑ WELL REPLACEMENT DESTRUCTION ❑ I PUMP INSTALLATION SY1STEM" ftAlF ❑ OTHER ❑ i ` �� SEWER LINES f 115 'DISPOSAL FLD. PROP. LINE + 2 DISTANCE TO NEAREST: SEPTIC TANK FOUNDATION —�� AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL. " PROBLEM AREA CONSTRUCTION SPECIFI pia. of Well Casing iJ ❑ In nal ❑ Open Bottom. ❑ Manteca Dia. of Well Excalation Specifications Domestic/Private ,ravel Pack fY ❑ Tracy Type of Casing S _ s ❑ Public r El Other ❑ Delta Depth of Grout Seal Type of Grout V ❑ Irrigation �4pprox.-De th Eastern urface Seal Installed by Repair Work Done ❑ Type of Pump H.P. St D Q . ` �^ r Sealing Material (top 50') Well Destruction -Wel�ametpiC � f g Depth `�� ,Filler Material (Below 50'} N.❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is TYPE OF SEPTIC WORK: NEW INSTALLATION, available within 200 feet.) _? ` Installation will serve: Residence Commercial_ ""Other k" Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to.nearest:' Well Foundation Property Line Total length/size LEACHING LINE ❑ No. & Length of lines I FILTER BED ❑ Distance to nearest: Well Foundation Property Line } Size I + Number l SEEPAGE PITS EJ Depth r SUMPS _ ❑ Distance to nearest:; Well Foundation Property Line I DISPOSAL PONDS ❑ `' 1: 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: '9 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 Yaws of California." Contractor s hiring or sub-contracting signature certifies the following:"I rtthat in the ormance of the work for which this permit is issued,I shall employ persons subject to workman's compensa- tion laws'of Califoml .' The appli st H r qui c ions. Complete drawing o�nr erse�s"id/e/� �A l Signed Title: t/r �V V 1 Date: FORD ARTMENT USE ONLY 1i� Date Area J Application Accepted by ate Pit or Grout Inspection by rr Date inal Inspection by "Additional Comments: 1 � ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 83543385 Applicant- Return all copies to- Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 CK FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. INFO v t`s Ia �ga +EH 1324(REV.t EH 14-28 :. 3.