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APPLICATION FOR PERMIT SAN JOAQUIN'LOCAL HEALTH DISTRICT 1601 E. MAZEL T ON AVE., STOCKTON, CA Telephone (209).466-6781 PERMIT EXPIRES 1'YEAR'FROM 'DATE ISSUED' fi: (Complete inpTriplicate) ... .1. - — off•.. . 5n y:: • - b.'. '�'_ 1'' 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. 1562 for well/pump and the Ryles and Regulations of the San Joaquin . 'Local Health District. �G Job Address Vs�,h ✓ e—J ''City �� of Size a PM 04 }i -6 r , Owner's Name Address 6-4Phone` � `7 p Y �1 Contractor �-/r R Addressn" y ice se No. Phone TYPE OF WELL'/PUMP:;; i"NEW,WELL'❑• WELL REPLACEMENT 11DESTRUCTION [I1 �4 TALLATION\❑ SYSTEM"AQ PUMP 1"NEPAIR,❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES' *'' { DISPOSAL FLD. PROP. LINE FOUNDATIONAGRICULTUtRE.WELL• OTHER WELL PITS/SUMPS INTENDED USE`S•-- _rTYPE.OF.WELL_._,PROBLEM AREA ..-.CONSTRUCTION SPECIFICATIONS- .❑ Industrial ) ❑ Open Bottom ❑ Manteca Dia. of Well-Excavation 1 Dia. of Well Casing ❑ Domestic/Private F1 Gravel Pack [I Tracy Type of,-Casing---- _ - Specifications' Q Public ," Ll Other ❑ Delta - +s Depth of..Grout.Seal's--`5-' Type of Grout - ia si - ;y ❑.Irrigation �4pprox. Depth ❑'Easterna "Surface Seal,lnstMIed by, Repair Work Dohe# O Type of Punip+" �_ .H.P,. f t" I State Work Done N'{ Well Destruction ❑ Well Diameter Sealing"Material (tap 501)-- -. Al c Ll r_; Depth '_ - ` y Filler Material (Below ) f } TYPE OF SEPTICWORK NEW INSTALLATION ❑ REP,AIR/ADDITION DESTRUCTION ❑ (No septic system.permitted if public sewer is T available within 200 feet.) ,, Installation will serve Residenceinmercial_ Other I C:I Number"of livin� units:r Number of bedrooms Character of soil to a'depth of'3•feet: at table depth SEPTIC.TANK s? I- Type/MfgCapacity_. No. Compartments PKG. TREATMEN7'PLT:❑ ___ Method of Disposal mi Distance.tonearest: Well Foundation-1 � Property Line _-�. '. LEACHING LINE + No. & Length of lines U Ttlength/size FILTER BEd ❑ Distance to nearest: Well 16Z Foundation-,eo_ Property Line� 7 t r ; SEEPAGE PITS I �• Depth Size Number i f SUMPS:. +; i ❑. Distance to nearest: Well __ Foundation - Property Line DISPOSAL"PONDS ❑ 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. r Home owner or lictsed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I skall not employ any personinsuch manner as to become subject to workman's compensation laws of California." Contractors hiring or sub-contracting signature r 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 California." The applicant must cal or Il required inspections. Complete drawing on reverse side. Signed X i� � L` Title: Da r _" FOR DEP TMENT USE ONLY Z. `�` . `Application Accepted by DaterP�fS1 Area it r Grout Inspection by Date J� al Inspection by Date Additional Comments:t A ❑ Stk 466-67811 ❑ Lodi 3621 _ Ma_nteca_82:1-7104., 0 Tracy 835-.6385__ Applicant- Returri'alf""copies'to:Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 20_.- �09, 4 FEE INFO AMOUNT DUE AMOUNT..REMITTED CK# RECEIVED BY DATE PERMIT`NO_ �1 +EH1324[REV.3/a 5} .�• - - EH 1426 S• Ch c,