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APPLICATION FOR PERMIT PeSAN JOAQUIN LOCAL HEALTH DISTRICT a C / 1601 E. HAZELTON ON AVE., STOCKTON, CA L� � Telephone (209) 466-6781 `` `,t PERMIT EXPIRES TYEAR FROM DATE ISSUED (Complete in Triplicate) `�, °:•: � ��1"Gj Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herei<des h.ed. 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. Job Address City if--- Lot Size PM Owner's Name G . L&. r � a r1 rf r Address L f�`!P Z ! Phone Contractor // T►1 c.�4 T- r Address !j(2 de -7 .C-�6 a License No.S�2 Phone_ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ M SYSTEM REPAIR 1 OTHER ❑ DISTANCE,TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE ------ FOUNDATION AGRICULTURE WELL f- WELL PITS/SUMPS INTENDED USEj_ :TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS w -"p Industrial © Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of.Well Casing Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications M Public l 1 Otherk C Delta Depth of Grout Seal Type of Grout _. I I Irrigation 1 - —.Approir.-Deptt�h_( } Eastern Surface Seal Install6d by _ Q Repair Work Done"r T Type of Pump H.P. ALU f State Work Done 92 f� Well Destruction,.f ❑ Well Diameter Sealing Material )top 501Ll F t =" Depth: Filler Material(Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION'I 1 REPAIRlADDITION 1_1 DESTRUCTION i 1 (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence Commercial Other 3 Number of living units: Number of"bedrooms Character of soil to a depth,of feet:, Water table depth _ 1 61 0�. _ .». 1. L.f f "SEPTIC,TANK- Ly.-I Type/Mfg Capacity No. Compartments "1PKG`TREATMENT PLT. ❑ Method of Disposal Distance•to nearest: Well Foundation Property Line _ f i� - - -- D LEACHING LINE Gi -_No,-& Length of lines Total length/size FILTER BED ❑" Distance to nearest: Well Foundation Property Line SEEPAGE_PITS- l I. Depth Size Number 1 SUMPS; ❑, Distance to-nearest,-'. Well Foundation Property Line DISPOSAL PONDS CI 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 Os§trict. 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, I shall not employ any pefson in such manner as to become subject to workman's compensation laws of California." Contractor's 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 California." t The applic ust jP111 for all requireFf pectin 70,, late drawing on reverse side. Signed XTitle: z �� S Date: FOR rPARTMENT USE ONLY Application Accepted by / Date Area 03,,, 1!, r Pit or Grout Inspection by i Date Final Inspection b Date Additional Comments: ' 1-1 ❑ Stk 466-6781 ❑ 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 1 FEE INFO AMOUNT�DUE AMOUNTREMITTED CASH RECEIVED BY DATE PERMIT"NO. +.EH 13-241REV.rin5) W��.. EH 14-28 �"�LL