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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (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 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- Job Address `� /'1�e City Lot Size r PM Owner's Name f�►7 ' - r� Address y 6v CK' '�(L Q Phone + / '6 Contractor's Name 72rLicense lVo. + ��,� _ _ - �'-"�r — Phone31�' TYPE OF WELL'/PUMP: NEW WELL WECU-FEpL4-C'E�"!"-""D STAOCTFb1V`❑':-- PUMP INSTALLATII�O//1N//1I. SYSTEM REPAIR ❑ 0 HER Mir DISTANCE TO NEAREST: SEPTIC TANK -SEWER LiNES DISPOSAL FLD. d�1r? PROP. LINE tZ-2— AGRIGUL-T:URE:WELL-I=:� -.OT•HER WELL PITS/S, , k INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS` s i ,pct ❑ Industrial pen Bottom ❑ Manteca Dia. of Well Excavation ,Dia. of Well Casing /r omestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing .LoapecrFcations 1©(1 si C3 i r❑ Public ❑ Other Q Delta Depth of Grout Seal — "T � ` t p �a .. � _pe.of Grout 'F I ED Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by j Repair Work Done❑-T Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') -TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system pe miffed if public sewer is " available within 200 faet.) t Installation will serve: Residence .Commercial 2 1# Other i - .,, , Number?of living units: Number of bedrooms - 4, Charact'r of soil to a depth of 3 feet: `�` _ Water-table-depth rl SEPTIC TANK ❑ Type/Mfg 1 Capacity 'f�i No. Compartments PKG. TRTTMENT PLT. El Method of DisRksal to Distance to clearest: well Foundation.d �Property LinetF Y - LEACHING LINE ❑ No. & Length of lines t ' 'I r^ ( Total lerigth/size FILTER BED ❑ Distance to nearest: Well r'--foundation.' ProperWy�Li a SEEPAGE PITS ❑ Depth Size Number t� "SUMPSQ 4 L] aistanceeto,pesrest: WeIF Foundation. =� - Rro a ~` "'� '� DISPOS ^PONDS ❑ y " I hereby ck rtify 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 oer 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 a y person in such manner as to become subject to workman's compensation laws of California." Contractoes 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 Iawstof Californi ." Thea ikant m I for a11're, � PP required i pectio late drawing on reverse side. Signed X� Title: ` Data:. FOR DEPARTMENT USE ONLY j.. nr Application Accepted by Date Area Pit rZGrou�Kpciio.en by ate , - Final Inspection by Date 111241015 Additions Comments: g " Y Stk 466-6781 ❑ Lodi -369-3621 ❑ Manteca 823-7104 l7 Tracy 835-63855 Applicant- Return all copies to: Environmental Health_ Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED 8Y DATE PERMIT•'NO. INFO +EH13.24'tRV.101581 4 �+ EH 1425 .. J a�