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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOC_KTON, Telephone (209) 466-6781 ' 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 hereiWiiescribed. 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. Job Address 3 City Lot Size/ �� ` PM Owner's Name4--u c, , Address Phone Contractor Address License Nea` Phone�� TYPE OF WELL/PUMP: NEW WELL ❑ ELL REPLACEMENT El DESTRUCTION ❑ PUMP INSTALLATION ❑ rJ SYSTEM REPQq'� OTHER ❑ DISTANCE.TO NEAREST: SEPTIC TANK SEWER LINES` i DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS 1INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS -❑ €ndustria! ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing # °y ❑ Domestic/Private ❑ Gravel.Pack ❑ Trac Type of Casing Y YP g Specifications �Q 1-1 Public - n Other n Delta Depth of Grout Seal Type of Grout _ ~ I I Irrigation '-=.Approx. Depth I i Eastern Surface Seal Installed by : Reiair Work pone ❑ Type of PumpH.P. State Work Done Well Destruction L2 Well Diameter Sealing Material (top 50') Depth ller Material (Below 50') :+ TYPE'OF SEPTIC WORK: NEW INSTALLATION EPAIR/ADDITIONK DESTRUCTION I I INo septic system permitted if public sewer is- InI available within 200 feet) stallation will serve: Residence✓Commercial_ Other Number of living units: _,t<_ Number of 9edrooms 3 _ Gharacter of soil to a depth of 3 feet: D,R t - Water table depth p / SEPTIC TANK O Type/Mfg Capacity— I v. No. Compartments PKG. TREATMENT PLT. 81 4 a i I f Method of Disposal Distance to near st: .- Well Foundation Property.Line LEACHING LINE No. & Length of lines _ \41 U� I�d" 1T tal length/size 0 FfL1ER BED Cl Ist'�CS ance to near`est:'t WeEI Foundation - _ Property Line SEEPAGE PITS 14-1 Depth Size �` � �a Number SUMPS- ❑ i Distance to.neare t: Wtf Fou loon OI Property Line, '/40 DISPOSAL PONDS ❑ t { hereby certify that I have prepared this application apd.-hat the work will be done in accordance with San Joaquin county ordinances3 state laws, and rules and regulations of the San Joaquin Local Health..DZWct Hone owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is Led, I shall not employ any person in such manner as to become subject to,workman's compensation laws of California."Contractor's hiring or sub-contracting signature ce i ifies the following: "I certify that in the performance of the work for which this permit islissued,1 shall employ persons subject to workman's compensa- tion laws of California." ... The applicant mus I d inspection. Campfete4dra'vving :rerrse side. Si (ned X �J C A R t-- _. Title: ,.._ Date: FOR DEPARTMENT USE ONLY r +� Ap lication Accepted by - + Date Area it or Grout Inspection by Date Final Inspection b to Ad Jilional Comments: © tk-466-6781-.-•--Q--Lod1-=369-362.1--- tg-Mar+teca-823-7.104 2 Tracy--$35.6385 Applicant - Return all copies to: Environmental Health,Peunlit/se�rvlc4s'1,60i7E.�Hazelton Ave., P.O. Box 2009, Stk., CA 95201 i� = - FEE AMOUNT DUE AMOUNT REMITTER CK RECEIVED BY PERMIT'NO.DATE INFO r—y CASSH /} +.EH13-24IREV.I/n51 � EH 14-26 - " II