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APPLICATION FOR PERMIT SAN JOAQUINLOCAL HEALTH DISTRICT 1601 E. HAZE%TON,AVE:,-STOCKTON, CA "laelello e)(209) 46616781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED A-0 : Tc>/_ f'' ` .(Complete in Triplicate)' - + t.•�".F . It FES' '��.. !'. Application is hereby made to the San+Joaquin Local Health District fora 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 Ryles and Regulations of the San Joaquin Local Health District..' Job Address _.�6.�.� /l/�if� -' .._'F Ci �tlmPit Size +a tPM a Owner's Name/ _te {�i1 Address`� I'1/�✓�/°1�'.. �. _ Phone r� t +' - Contractori Address G License No. Phone iii TYPE OF.WELLl,PUMP,:'. , EW WELL WELL REPLACEMENT ElDESTRUCTION ❑ 1 PUMP,INSTALLATION ❑ ' SYSTEM REPAIR OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES 1 DISPOSAL FLD. PROP. LINE rd,�. .e ,.1r•G P 4f_ � e+rka-� 1 L_.r.--r ..� $___. ,,..'FOUNDATION AGRICULTURE V1/EL'L OTHER 'WELL PITS/SUMPS INTENDED USE` TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ IndustrialLIOpen Bottom 1-1Manteca Dia:o1,Well Excavation Dia. of Well Casing . Ll Domestic/Private �❑ Gravel Pack ❑ Tracy Type=of Casing Specifications ❑ Public > ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation ; { --Approx. Depth ❑ Eastam Surface Seal Installed by ew Repair Work Done ;Type of Pump H.P,f, I State Work Done4� c Well Destruction ❑. ?Well Diameter. Sealing Material (top 50') Oz. depth Filler Material (Below 50') TYPE OF SEPTIC WORK:. NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_�,Other (7 Number of living units: % Number of bedrooms ! f Character of soil to a depth of'3,,feet: r Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ k Method of Disposal Distance to nearest: Well FoundationProper[y Line C—,- LEACHING -,-LEACHING LINE ❑ No. & Length of lin s '• -length 9 E ��''"'� •'Total /.siz FILTER BED ❑ Distance to nearest: ? Well Foundation : t a Property Line SEEPAGE PITS ❑ Depth ,. __ Size ts`. r S y - Number SUMPS ❑ Distance tariearest: W Well f aundation `Property Line krt L J.� DISPOSAL PONDS ❑ $...�.�+,Y., t hereby certify that I have prepared this application and that the work will ibe done in aAordance with San-J&quin county ordinances, state laws, and rules anpegulan an Joaquin Local Health District.Home osedagen signature certifies the following: "I certify khat.in.,the rformance of the work for which thispermit isissued, I shall notemploy n such man er`�as to become sub'ect to workm corripe sa n ws of California."Contractor's hiring or sub-contracting signaturecertifiesg '°I certify t m the_pertorm ce of thew f which h' per it is issued, I shall employ persons subject to workman's compensa- tion lawi .'The appor require inspect' ing on er sid*AM:!?,AZ Signedv i Date: FOR DEPARTMENT USE ONLY i Application Accepted by _ ' Date J Area Pit or Grout inspection by a Date Final Inspectio by Date .ate Additional Comments: E'r ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 873-7104 ❑ Tracy 835-6365 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009!Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH CK RECEIVED BY PATE PERMIT NO. 1 : +EH 13-24{REV.I/e 5) J� C` I�., c1.. .. EH 14-26 . '—lr> {\.P .