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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E, HAZEL-J ON AVE.,,STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM,DATE ISSUED (Complete in Triplicates ►� ,; , 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. 1 PM- eaf Job Address �� City Lot Size SdrAd Owner's Name WWII Address p ._ Phone Contractor,�LL� I Address License No. Phone TYPE OF WELLIPUMP- I NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL-FLD. PROP. LINE C FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS �J ❑ Industrial ❑ a irpen Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private © Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Olther ❑ Delta Depth of Grout Seal Type of Grout ❑ IrrigationIMApprox. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material {Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION VDESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Resid�nce_Y. Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Savoy Cb,Y Water table depth SEPTIC TANK ❑ Type/Mfg j Capacity No. Compartments PKG. TREATMENT PLT. ❑ IN Method of Disposal Distance to nearest: Well Foundation Property Line 0 r .I LEACHING LINE ❑ No. & Length of lines d Total length/size FILTER BED Distance to nearest: Well A'16_r_ Foundation Mf Property Line IM � I SEEPAGE PITS ❑ Depth Size Number .SUMPS ❑ `Distance to nearest: Well Foundation :Property Line ` DISPOSAL PONDS ❑ II 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 I rules and regulations of the San Joaquin Local Health District. I Home owner or licensed agent's signature certifies the following:"'I certify that in the performance of the work for which this permit is issued, 1 shall not employ any person in such manner as to become subject to workman's compensation laws of California."Contractors 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 laws of Ca' nia." € The applica st call for all !`e 'ed i pectin Complete drawing on reverse side. Signed X Title: Date: i FOR DEPARTMENT USE ONLY i (� Application Accepted by Date Area O O Pit or Grout inspection by I�' Date / Final Inspection fby Date 6/A%�—d I� 3S3 S / /fir �er.� T �( /1 Additional Comments: ! � � W��"!�� 15 /5 ❑ Stk 466-67B1 Lodi 369-362 © M nteca -7104 ❑ Tracy 835-6385 /oe /nS aGR- Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 IFEE NFO ASV 0 NT DUE AMOUNT REMITTED K RECEIVED BY II DATE PERMIT'NO. + EH 18-241REV.1/851 EH 14-26 ! to