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k APPLICATION FOR PERMIT I SAN JOAQUiN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA ' Telephone (209) 466-6781 f 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 % E Cit lj�9itl%/¢ 4 y y Lot Size PM Owner's Name` F Address ' — # Phone Contractor 4 Address �:.`y License No. � phone. TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT Li DESTRUCTION ❑ PUMP INSTALLATION EDWELL SYSTEM REPAIR C1 OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK fit SEWER LINES a 1 �. rDJSPOSAL.FLD, PROP. LINE r '\,^,FOUNDATION-' _ AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE _TYPE"OF WELL PROBLEM AREA CON STRUCTIONiSPECIFICATIONS ❑ Industria!r = — ' $ 1 Open-Bottom ❑ Manteca Dia. of Well Excavation ❑ Domestic/Private ❑_Gravel%Pack,' 4' ,Dia. of Well Casing ' ❑ Public �`: d i ❑„Tracy Type of Casing 2i r J Specifications -❑Others u,,t ❑,Delta Depth)of Grout'Seal ❑ Irrigation C a l f Type of Grout pprox.,Depth ❑ Eastern Surface Seal lgsta�led by '` i.'. _ 1> ; Repair WorkDone ❑ Type of Pump H.P. I State Work Done_ Well Destruction ❑ Well Diameter ' 1 Sealing Material (top 5011 ' 2 i E I Depth' Filler Material IB_elow 50'}_ I TYPE OF•SETfC WORK: NEW INSTALLATION EliREPAIR/ADDlT10N`• DES7RUGTlON ❑ iNo septic system permitted if public sewer is a _ rin�stallation�ill serv '`fe: sidence available within 200 feet.) I Numher of living units ` i ; ► ” " "— — - -__ __ 9 Number of,b_edrooms Character of sad to a dept 3 feet:t d SEPTIC TANK 4 ,, - Water table depth + 4: opacity� xy %Z PKG. TREATMENT PLT. F] :- � _ No. t .Compartments.;' Method bf Disposal Distance to nearest Welt Foundation F � Property Line - LEACHING LINE - at ,y x No. & Length of'lines ,� ' FILTER BED / *� r Total length/size I /- ❑ Distance to nearsiWell L� ' Foundation D '12- 4 # �_ Property Line SEEPAGE PIS ❑" Depth Size � � SUMPS nI Ni}mber ❑ Distance to nearest- Well Foundation . Property Line DISPOSAL PONDS ❑ ! hereby certify that I have prepared this application and that the work will be done in accordance With I'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: } + employ an 1' ; 9 �'I certify that in the performance of the workifor which this permit is issued, I shall not P Y y person in such manner as to become subject to workman's compensation laws of-California."%Contr`actor s hiring or sub-contracting signature � certifies the following: "i certify that in the performance of the work for which this permit istissued, I shall employ persons subject to workman's compensa- tion laws of California.'' l , The applicant must call for all qui �� — � __ q spections. Complete drawing on reverse side. Signed X ? r ,Title: DatiI _ FOR DEPARTMENT USE ONLY "'`4 Application A�ceI by �, Date Area o ' o Pit or Grout inspection by Date Final Inspection•'I , ;. Additional Comments: Cl Stk 466-6781 @ ❑ Lodi .369-3621 ❑ M�a"i823 7104 Tracy 835 fi385 Applicant- Return@II copies to: Environmental HealthSenrices 1601 zelton Ave., P.O. Box 2009?Stk.!, CA 95201 FEE INFO AMOUNT- . �OIJNT;�p� . CK_# ,AS t�E - •.+-EH13.24[REV.iiHslHC iVED•BY^---� -- DATE "PERMiT�'NO"�' EH 1426