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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE.T ON 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 Rules and Regulations of the San Joaquin Local Health District. Job Address Cit �-� Lot Size PM Owner's Name IV Address Address Phone F Contractor Address r License N Phone TYPE OF WELL/PUMP: W WELL ❑ "WELL',REPLACEMENT"❑ DESTRUCTION ❑ .^...,,,: PUMP-INSTAtL•ATION.-F)-- .-"_"SYSTEM"REPA'1R...D,-' "�_—'.OTHER-C9----- DISTANCE TO NEARESTz,SEPTIC�T,A°T4Kt---SEWER LINES DISPOSAL FLD._,-_. PROP. LINE FFOUNDATI01 _ AGRICULTURE WELL OTHER{{WELL L PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Industrial - D Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing I Domestic/Private 0 Gravel Pack ❑ Tracy Type of Casing r� r, 'Specifications 1 Type of Grout : �f'1 Public """�- �-..,,,,111 Other I l l:Delta Depth of Grout Seal T -- � - �kl I Irrigation ..-. .L #pprox,.Oeptfa,--f-(.Eastern ''� Surface Seal.�lnstalled by Repair Work Done ❑ Type of Pump " # ,'H.P'+' _' State Work Done i "t Well Destruction ElWell Diameter Sealing Material-(top 50'9'' ` Depth Filler Material (Below-1501 TYPE OF SEPTIC WORK: NEW INSTALLATION, q- REPA01ADDITION l I DESTRUCTION 11,(No septic sysiem permitted if public sewer is sy-= =available withifr 200 feet.) t�y Installation"Witt"Serve: Residence�Commerci I_ Other I W # .Number living units: Number of edrooms I il —� ``,,: � w y Water tale epth v ;, Gharacter of soil to a depth of 3:feets. SEPTIC TANK Type/Mfg j Capacity,�G� No. Corripar ments P& TREATMENT PLT. ❑ _ I / Method of Dispose, i Distance to nearest: Well Foundation) ZZ> '_ Propeny.Line f ! LEACHINGNo. & Length of lines r Total length/size ff _ FILTER BED R ❑ Distance to nearest: Well - at YtT at oni e'r-r""" _P.roperty-tiny" SEEPAGE PITS I I Depth �� Size X j;?= — Number 3 SUMPS ._ v-^�-Distance-to-nearest- --Well�� foundation_dIVQ Property Line 0Z.V_ DISPOSAL PONDS ❑ s '/ I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin countyordinances, 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 which this permit is issued, I shall not, employ any person in such manner as to become subject to workman's compensation laivr of California." Contractor's hiiing 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." 44 t i 3 Theapplicant t call fora squire � spections. Complete drawing on revers side: Signed Title: a . FOR DEPARTMENT USE ONLY 1 s. �� Application Accepted by - ^� �"� �`�'`'�'�- � Date v "'" Area 2-2 � .Pt tnspectioy nbyeDate LV" ~D ° Iinal Inspection by` ' Date��'2 " Additional Comments: r„0 Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 T-❑ Tracy 835-6385 t Applicant - Return all copies to: Environmental Health Pefmit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE_. PERMIT NO. INFO +.EH 13-24(REV,t i H 5) f�l�,g� glr_:1 y772 EH 14-26 J