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4 , APPLICATION FOR PERMIT • SAN.JOAQUIN LOCAL HEALTH DISTRICT G 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 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. Job Address _� V City��T.C7�ot Size PM O , , Owner's Name - Bdress _ �,(-_ � Phone Contractor_ [ �i�IL� ddress ' License No. 324t3—Phone TYPE OF WEL1 !PUI4AP:=---�• �,N5yy WELL IJ WELL REPLACEMENT❑ DESTRUCTION [D PUMP INSTALLATION ❑ --'fie! IVSTEM REPAIR.❑r OTHER_-❑ DISTANCE TO NEAREST: SEPTIC TANK "�`AL OP.LINE SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS I INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS a ❑ industrial ❑ Open Bottom ❑ Manteca _Dia. of Well Excavation Dia.. of Well Casing El Domestic/Private 1-1GravelPack ❑ Tracy -� Type of Casing ❑ Publicg }Specifications ❑ Other 1 El Delta Depth of Grout Seal - F] Irrigation i Type of Grout 1 --Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth I Filler Material (Below 50'1 3 TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ DESTRUCTION f {No septic system permitted if public sewer is ! available within 200 feet.] Installation will serve: Residence Commercial_ Other / - e Number of living units: iNumber of bedrooms Character of soil to a depth of 3 feet: SEPTIC TANKType/Mfg I .. ,.- Water table depth L f �( -�- - PKG. TREATMENT PLT. ;Capacity-X1as�No. Compartments [2r i ---- •M __�.�..,.......,.� _ , �,,,,�,•, s �' " Method of Disposal Distance to nearest: Well 1Four�daticn Property Line ; LEACHING'LINE ❑ NoA Length of lines f Total length/size # yFILTER BED ❑ Distance.to nearest: Wel! Fo{nidation 3 u- # Property Line .. SEEPAGE PITS ❑ Depth Size l Number SUMPS F] Distance to nearest: Well Foundationi Property Line DISPOSAL PONDS ❑ 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. Home owner or licensed agent's signature certifies the following:"'I certify that in the performance of the work for whal hich this permit is issued, ! sl not employ any person in-such mhnner as to bec "I cerd t in thome subject to workman-s compensation laws of California."Contractor's hiring or sub-contracting signature certifies the folio 'ng: e performance of the work for which this permit is issued, I shall em to ° tion laws of Calif P Y Persons subject workman's compensa- The applicant t call for II re uirnspections. Complete drawing on reverse side. Signe Title: Date: _ _ F FOR DEPARTMENT USE ONLY Application Accepted by1� r a Date ` Q1.1 Area t Pit or Grout Inspection by Date Final inspection by is^ �� } Date Additional Comments; _ I ❑ Stk 466-67814& El Lodi 369-3621 . ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT',DUE. -AMOUNT REMITTED CK# - lNFO ^°00 CASH' ^�-RECEIVE6.BY a —DATE— PERMIT"NO.Y- + EH 14-2atREv.,iesr ��f3 ��'�� EH 1426 � ..