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f ' h .4 N FOR PERMIT SAN JOAQUIN LOCA APPLICATION HEALTH DISTRICT 1601 E. HAZE T ON AVE., 5TOCKTON, CA Telephone (209) 466-6181 i IV 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 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. T. w•, . ,.,. pry p ,�•L_ }, �;, r� s. - Job Address , Ses M ►y1Yk _ City ` Lot Size n PM Owner's.Name Address. - - - Phone Contractor AxL�l MCAddress CLpaha License No. 08 Al Phone q? TYPE OF WELL/PUMP: NEW WELL❑ WELL REPLACEMENT-❑ DESTRUCTION ❑ V PUMP INSTALLATION,�p� � SYSTEl1±I�AEf41R �" OTHER❑ (f DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS W ❑•Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casingf ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta - Depth of Grout Seal Type of Grout ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by ( ,f Repair Work Done ❑ Type of Pump H,P, State Work Done 111 Well Destruction ElWel! Diameter -- wSealing_Material_(top-50') s Depth Filler Material (Below 501 tl W I TYPE OF SEPTIC WORK: NEW INSTALLATION ElREPAIR/ADDITION Z—aeSTRUCTION ❑ (No septic system permitted if public sewer is ° available within 200 feet.} Installation will serve, Residence�.�ommerc} ial `'Other, j Number of living units: --L Number of bedrooms Character of soil to a Idepth 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 ) LEACHING LINE 11—.Ne. & Length of lines Total length/size 4 FILTER BED ❑ Distance to nearest:. Z„ Well. Foundation Property Line t SEEPAGE PITS LL—Depth C ' Sill Number SUMPS ❑' Distance to nearest: Well Foundation a o Property Line P DISPOSAL PONDS ❑, r ; ' f I hereby certify.that I have'prepared this-applicaiion and that the work will be done in'accordance with San Joaquin county ordinances, state laws, and I rules and regulations of'theSan Joaquin Local,'Health District. Home owner or licensed;agent's signature.certif es the following: "I`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 workmanll c mpensation laws of California." Contractor's hiring or sub-contracting signature certi ' the following: "I certify that in the performance of the'work for wh}ch this permit is issued,I shall employ persons subject to workman's compensa- tion la f Calif" ia." i The app'}can st ca for re �e � plate drawing on reverse sid - 4 4 7 7 Signed hTitle: Date: J r� i[ FOB DEPARTMENT USNLY Application Accepted by. ' Date ^� ^ Area Pit or Grout Inspection by # Date Final Inspection by C -`/ .-�� Date i Additional Comments: t ❑ Stk 466-6781 p Lodi 369-3621 #❑ Manfeca 823-7104 ❑ Tracy 835-6385 ' Applicant - Return all copies to: Environme taf:Health Permit/Services 1601 E. Hazelton Ave., P.O. Bax 2009, Stk., CA,95201 AFEE �. INFO AMOUNT DUE AMOUNT REMITTED CLASH RECEIVED BY. DATE PERMIT"'NO. c + EH 13-24(REV.tis51 l• -r_ � — �..a. �� J((� �\��/ EH'1426 AL t