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1'oU ; APPLICATION FOR PERMITSr �d SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 t � 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 e made H compliance with San Joaquin County Ordinance No. ein e Local Health District: " 549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the applian cation in Job Address r• Y nY u• z_ L/ City $ .. t. a Owner's NamLot Size e-c�`//yJ/YI i - - PM �� .'Address Phone Contractor� D ;-�••K+--� .,4.,,. �.,�''� �ll� ��Address , W wAl 4-k TYPE OF WELL/PUMP: NEW WELL-0 1 License-No. YZ�76 WELL REPLACEMENT ❑ Phone 7 PUMP INSTALLATION ❑ DESTRUCTION ❑ DISTANCE TO NEAREST: SEPTIC TANK;f ? ''� SYSTEM REPAIR_❑ — SEWER LINES OTHER ❑ �� DISPOSAL'FLD. FOUNDATION;' PROP. LINE " —� AGRICULTURE WELL OTHER WELL 4 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIDNS P1TS/SUMPS ❑ Industrial ❑ Open.Bottom - ❑ Domestic/Private ❑ Manteca Dia. of Well Excavation i ❑ Gravel Pack ❑ Tracy T Dia. of Well Casing ❑ Pubfic ❑ Other Type of Casing j66. ❑ Delta Depth of Grout Seal 1 Specifications wj ❑ Irrigation -� ..:ppprox. De Depth ❑ Eastern 5 rface Seal Installed by ` Type of Grout Repair Work Done ❑ 'Type of pump H.P. y. ❑ Well Diameter _ State Woi•k Done_ Depth j� Sealing Material{top 50'j TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIRlTIDDITiON ❑so D STRUCTION � 1 €' (No septic system permitted if public sewer is V Installation will serve: Residence available within 200 feet,] iCommercial Other t Number of livingunits: {`°"-� I j Number'of bedrooms Character of soil to a depth of 3 feet: I` SEPTIC TANK Type/Ak9L1 + Water table depth PKG. TREATMENT PLT. ❑ ;' Capacity No. Compartments0 .. ..Distance to neatest: I Method of Disposal Well i Foundation Property Line�� r LEACHING'LINE ❑ No. & Length of lines~`�c T FILTER BED Y Total length/size ❑ Distance to nearest: Well i I :+ Foundation � Property Line P I f � SEEPAGE PITS ❑ 'Depth Size 'f SUMPS Number f ❑, Distance to nearest: Well Foundation DISPOSAL PONDS Ela Property Line I I I hereby certify that 1 have prepared this application-and-that the-wok,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 followin employ any person in such manner as to become subject to workman's kman's clompensation lfy that in the aws of California,"Contractoformance 0 eTwork for rys'hiring]oPsub sub-contracting I shall not y certifies the following: "I certify that in the p rfo;mance of tfle work for which this permit is issued, I shall employ tion laws of California." ! ng signature p y persons subject to workman's compensa- tion applicant must call for ail required inspectiComplete drawing on.reverse side. Signed X to / I Title: Date: FOR DEPARTMENT USE ONLY Application Accepted by t D Pit or Grout inspection Date Area_ . Date. _4 Fpnal inspectionby� Additional Comments: ��" Date ❑ Stk '466-6781 ❑ Loi 369-3621 } ❑ Manteca -7104A'�,/❑ Tracy 835 6385 Applicant- Return.all.copies.to:_Environmental-Health-Permit/Services-1601 Er Hazelton Ave.T P:O'Box-2009,-Stk';CA 95201' FEE INFO AMOUNT DUE AMOUNT REMITTED K C H RECEIVED BY DATE AERjMN . EH 13.14 MEV.i i x 51 –'"�- — �,.;: i.� ;. J_ _f .,., _ EH 1428 1� - 1'V 3 e I