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= 1 APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT j 1501 E. HAZELTON AVE., STOCKTON, CA h 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 in County Ordinance No. 549 for sewage or No. 1862 for wa made in compliance with San Joaquin Ili pump and the Rules and Regulations of the San Joaquin i Local Health District. - � 1 �2 City�T Lot Size� PM Job Address Phone _�--- Q .tum•,' ' Address fy �j owner's Name T License No. ^�3r -y gi`3 !>"� %-sem 1 Addressq -� �L-.�6 Phone WELL REPLACEMENT ❑ DESTRUCTION.❑ Contract r TYPE OFA NEW WELL ❑ SYSTEM REPAIR 13 OTHER-0-a v PUMP INSTALLATION l.Y SEWER LINES DISPOSAL FLO- PROP- LINE DISTANCE TO NEAREST: SEPTIC TANK OTHER WELL PITSISUMPS FOUNDATION AGRICULTURE WELL TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Ola. of Well Casing - INTENDED E ❑ Manteca Dia.of Well Excavation ❑ Ind stria/ ❑Open Bottom Specifications � � ❑ Tracy Type of Casing domestic/Private ❑ Gravel Pack Type of Grout_ - Depth of Grout Seal I'1 Public, fl Other ❑ Delta Surface Seal Installed by t _ I I Irrigation Approx• Depth l Eastern )* Slate Work Done tfL- Type of Pump H.P. •- :..a �.ydtepair Work Done Sealing Material (top Well Destruction ❑ Well Diameter -. Filler Material (Below 501 ,Depth" u septic TYPE OF SEPTIC WORK: NEW INSTALLATION L1�9EP?IR/ADDITION I DESTRUCTION I 1 aNaitable wth! 200 feetpermitted if public sewer is -A Commercial_ )Other ' Insitallatin will serve: Residence .— .t, -1 Number of of edrooms--^-- Number of living units: bedrooms Water table depth ... r Character of soil to a depth Of 3 feet: CapacityNo. Compartments r SEPTIC TANK ❑ Type/Mfg Method of Disposal PKG. TREATMENT PLT.01• r.�„r Distance to nearest: Well Foundation Property Line Total length/size , LEACHING LINE - Cl No. & Length of lines property Line i Foundation FILTER BED ❑ Distancepo marest: Wall 4 X - ' Number l-5• S SEEPAGE PITS { I Depth ize Property Line Foundation—.— 1 SUMPS Ll Distance to nearest: well I DISPOSAL PONDS C3I hereby certify this application and that y that I have prepared the work will be dons in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin local Health Dutrici. Permit is issued,1 shall not }tome owner or licensed agent's signature certifies the following:"I certify that in the rformance of the work for suns ring so workman's campensa- 1 shall employ pe employ any parson in d a manner as to become subject to workman,s compensation laws of Calilomia:' 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, tion laws of California" a Tho applicant must a for all r@q ed inspections. Comdata drawing on reverse ide. Date: Title: I signed X R DEPARTMENT USE ONLY �6 Z Date Area" - ��—' ��QQ—��2 Application Accepted by Date>;z../�-,<rs� PR or Grout Inspection by Date Final Inspection by �i !! ' Additional Comments: ❑ Tracy 835-6385 ❑ Stk 486-8781 ❑ Lodi 389-3621 ❑ Manteca 823-7104 Applicant- Return all copies to: Environmental Health Permits Services 16001 E. Hazehon Ave., P.O. Box 2009,Stk., CA 95201 RECEIVED BY DATE PEI1MIT'NO. FEE AMOUNT DUE AMOUNT REMITTED CASH r INFO �I30 O 0"10 Z.- ..EH 13-14 IaEV.Nxs) Ell W20