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APPLICATION FOR PERMIT i SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELiON AVE., STOCKTON, CA Telephone (209) 466-6781 F PERMIT EXPIRES'? YEAR FROM DATE ISSUED f (Complete in Triplicate) ` :a -, lication is is hereby made to the San Joci aquin Local Health District for a permit to construct andlor install the work herein de Regulations of t s Sa Application Ordinance No.549 for sewage or Not 1862for wel�lpump and the Ryies and Regulations of the San Joaquin made in compliance with San Joaquin County ;. Local Health District. ` PM C•ItY Lot Size . Job Address rr Phone ph! G Add ss Owner's Name i �j]�� o. Phone1AKense N �� AddressDESTRUCTION ❑ Contractor WELL REPLACEMENT 11r. NEW WELL ❑ OTHER ❑ TYPE OF WELL/PUMP: SYSTEM REPAIR ❑ PROP. LINE j PUMP INSTALLATION ❑ DISPOSAL FLO. SEWER LINES __ — OTHER WELL. PITS/SUMPS DISTANCE TO NEAREST: SEPTIC TANK �r AGRICULTURE WELL FOUNDATION �— } INTENDED USE TYPE OF WELL PROBLEM CONSTRUCTION SPECIFICATIONS Dia of Well Casing ❑ Open Bottom El Manteca Dia. of Well Excavation Specifications ❑ Industrial Type of Casing r ❑ Gravel Pack ❑ Tracy Type of Grout ❑ Domestic/ � pelta depth of Grout Seal a C] Public ❑ Other t ' ---Approx. Depth Q Eastern Surface Seal installed by ❑ Irrigation r H P State Work Done Repair Work Done ❑ Type of Pump Sealing Material Itop 50'1 Well Destruction 13 Well Diameter —� Filter Material (Below 50'),,, 1 Depthermitted if public se is :i available within 200 feet.l TYPE OF SEPTIC WORK: NEW-INSTALLATION ® REPAIR/ADD ❑ DESTRUCTION ❑ INo septic sy e Installation will Sarre: Residence_X_ Commercial— Other !�1 Number of bedrooms Water table depth i Number of living units: a l Character of soil to a depth of 3 feet: Capacity_ ©� N°• Compartments SEPTIC TANK AL Type/Mfg Method of Disposal I PKG. TREATMENT PLT. D �'3— Foundation-9-5-- Property oundation Q5_ Property Line r Distance to nearest: Well d �,//V/ Total length/size LEACHING LINE No. & Length of lines .r ,6 Property Line -- Foundation 41/l—/ FILTER BED Distance to nearest: Well ^� Number ❑ Depth Size SEEPAGE PITS` Foundation Property Line�— SUMPS l ❑ Distance to nearest: Well D15P05AL PONDS _ ❑ rt hereby certify that I have prepared thisapplication and that the work will be done in accordance with San Joaquin county ordinances, state laws, and l he Y j rules and regulations of the San Joaquin Local Health District. ~I certify that in the performance of the work for which this permit is issued, 1 aha not Home owner or licensed agent's signature;certifies the following: " Y persons subject to workman's compensa- employ any person in such manner as to become subject ofothe work for wh ch this permit law wsissued,fi shall employ pe Contractor's hiring or sub-contracting signature certifies the following: I certify.that'in the per ; tion laws of California." ��eb� �-- The applicant must call for all required inspect ns. Complete drawing on reverse side. pate: .2 f r� Title: t Signed FOR DEPARTMENT USE ONLY �� Date Area I Application Accepted by Date K" Final inspection by Pit or Grout Inspection by Date — Additional Comments: -7104❑ Lodi ices 1601 E. Hazelton Ave., P.O. Box r -3621 Q Manteca 823EITracy. 835-6385Stk., CA 95201 E3Stk 466 6781 Applicant- Return all copies to:Environmental Health Permit/Sery , G RECEIVED BY ' DATE PERM IT'N0. I FEE AMOUNT DUE MOUNT REMITTED 1� 1 INFO W_ j7��r�S �St1f 1 +EH 1324(REV.t/8 51 060 - EH 4426 - • '