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- APPLICATION,FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT ' y 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED k (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 Rules and Regulations of the San Joaquin II Local Health District. ' �. �.. � 5-r :. ,��. � -,•'e s -.. r �t+� . �,:,; i , �. Job Address3 L7 � � ��.. .,� .,, e;,. � .,:F`� � , r R. -! �Sf "" City L Lot Size - Ls� l i PM Owner's Name 'Address -Zp .d. yPhone W 1. ContractorL LAddress TD r eLA .License No._`7 3h Phone s�� TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION L7 P-UMP-INSTALLATION-4=1--------SYSTEM-REPAIR-❑ OTHER-C7 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. 'PROP:'LINE i FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing } 171Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Pubic ❑ Other, ❑ Delta �. Depth of Grout SealType of Grout ❑ Irrigation _Approx. Depth ❑ Eastern % ` Surface Seal Installed by Repair Work Done ❑ Type of Pump E H.P. ' State Work Done� ( Well Destruction l] Well Diameters Sealing Material /fop 50''1 Depth I' � � Filler Material (below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION CC--DESTRUCTION ❑ (No septic system permitted if public sewer is !� ` '-'` ,available within 200 feet.► E Installation will serve: Residence— Commercial_ Other r< /" Number of living units: Number of be 43 _ Character of soil to a depth of 3 feet: -+- } X F Water table depth SEPTIC TANK ❑ Type/Mfg' PKG. TREATMENT PL7. ❑ "I ^��^; f r I Capacity _ Noti Compartments I � Method of Disposal -nearest,,,,. n Distance to-nearest,,,,. � Well Foundation Property Line ` V� LEACHING LINE moo. & Length of lines. 4 Total length/size / FILTER BED" ❑ Distance to nearest: Well- � foundation=.��Property�Line I 1 SEEPAGE PITS L7 Depth Size Number �- SUMPS ❑ Distance to nearest: Well - Foundation Pro e DISPOSAL PONDS ❑ p rty'Lme � I hereby certify 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. ,t Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for►which this permit is slued, I shall not l 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 fies 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 I Fof California." 1 The applica u t call or al requi=,qsc s. Complete drawing on reverse side. I gne Title: i Date: ` - { FOR DEPARTMENT USE ONLY Application Accepted by r Datef Area r' Pit or Grout Inspection by Date +Final Inspection byjD ' Date Additional Comments: r ❑ Stk '466-6781 ❑ Lodi 369-3621 ❑ Manteca 623-7104 't=betracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services.1601 E'-XHazelton Ave., P.O. Box 2009, Stk., CA 95201 ' { FEE AMOUNT DUE AMOUNT REMITTED INFO CASH RECEIVED BY DATE PERMIT'N0. t EH1 -241REV.I/R5M EH 1428