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t APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) i 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. YLl/J 1� Ci b l of Size�-: ,V PM I Job Address h+ Owner's Name IM Address ee-A .S4Aili "OS45- Phone � { Contractor's Name "S License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ 1 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS ' P �r y INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS "� Owlndusirial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑-Domestic/Private —❑-Gravel-Pack—El.-Tracy --.--.-,-Type of-Casing - - -Specifications- -- - - -wµ- ❑ Public "+- ❑_Other ti �El'Delta`1% Depth of Grout Seal _- yp�e°_of Groin- ,.-__Approx..,Depth -,13_Eastern �_ Surf_ace Sea_! Installed by. ~ ,Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter s Sealing Material (top 501 Depth Filler Material (Below 50') _- TYPE OF,SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION DESTRUCTION ❑ (No septic system permitfW-if public sewer is r _ available within 200 feet:l" r V Installation will serve: Residence 174)t- -Commercial=OtIjer Number of living units:__/_ Number of bedrooms i t 'cr t Character of soil to a depth of 3 feet: Water table depth Zz -C SEPTIC TANK ❑ Type/Mfg ' Capacity. No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal { Distance to nearest:. _Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines 1 Total length/si e�- 11 ' - � f FILTER8E6,- ❑ Distance to nearest: Well Foundation _ Property Line - t" as SEEPAGE PITS Depth �' Size ` umber -SUMPS ❑ Distance to nearest: Well Foundation S 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`S en-Joaquin Local Health District. Homeowner or licensed'agent's_signature�certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not + employ any person'ir such-manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature certifiesAfolloing.,:'A certify that in the performance of the-work for which this permit is issued, I shall employ persons subject to workman's compensa- Ltion lawTlieappfor all equired s ctio Co plete drawin n Fse side. Signed Title: Date: C'7 FOR-DEPARTMENT-FOR_DEPARTMENT U5E ONLY j. Application Accepted by Date �` Arpa ---TP_it or.--Grout_Inspection. _Date-/ � Final Inspection b Date- .. --Y-..—.. �.. _...... . - Additional Co Y an .� { ❑ Stk 466-6 ❑ Lodi 369-3621 ❑ Manteca -7104 4,710 Tracy 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# RECEIVED BY DATE PERMIT"N0. INFO CASH + EH13-24{REV.10/03y S EH 14-28