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=APPLICATION FOR•PERMIT - SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZETON 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 Heaith District. ^^ Job Address d {p tr City P & Lot Size PM t ,SG iM G Owner's Name � �� Address Phone� - :tt Con�traclar _ O r a Address CS u License Na S Phone "Z- 7 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION El SYSTEM REI'AIR-0 - '`'"""`OTHER-Cl— DISTANCE TO NEAREST: SEPTIC TANK SEWER;LINES t .DISPOSAL FLD. PROP. LINE t FOUNDATION AGRICULTURE WELL OTHER WELL ~ PITS/SUMPS t INTENDED USE TYPE OF-WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca ;�Dia:. of Well Excavation Dia. of-Well Casing ❑ Domestic/Private 0.Gravel Pack ❑ Tracy Type of Casing N Specifications'( ("1 Public (7 Other 171 Deltas Depth of Grout Seal Type of.Grout�__' _ I E Irrigation _-Approxi Depth i I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done i Well Destruction ❑ Well Diameter Sealing Material (top 50')-. f Depth * _; Filler Material (Below 50'l - '- TYPE OF SEPTIC WORK: NEW INSTALLATION il REPAIR/ADDITION l 1 DESTRUCTION I I INo septic system.-permitted if public sewei,is' I! available within 200 feet.I Installation will serve: Residence Commercial_ Other Number of living units: —I-- Number of,.bedro Character of soil to-a depth of 3 feet: �* � O ,e. Water table depth SEPTIC TANK 1✓f lld'.Type/Mfg _(�ts/l�f� •lamip Capacity _ ..f No. Compartments PKG. TREATMENT PLT. ❑ - i = f" Method of Disyosal Distance to nearest: Well `70 Foundation 10 _ Property Line 17 . •� LEACHING LINE No. & Length'of,(ines , T9tallens gth/size- FILTER BED ❑ ''Distance to nearest: Well ram Foundation. a Property Line SEEPAGE PITS l I ,f'Depth n"`R Size nlV�mbe`r.. SUMPS - - •&yK Di"stalii;e to nearest: Well 1 a Foundation, Property Line 1 DISPOSAL PONDS '-❑, a. I hereby certify that I have prepared this appkaiion arid than the work will be done in accordance with San Joaquin county ordinances, state laws, an i� rules and regulations of the San Joaquin Local Health District'"" ""�"�',""'-wor which his permit ---Home owner-or 1hcensed agent's signature certifies the following: "I certify that�he performanceiof the work far which this permit is issued, l shall not employ any person in'sueh.manner as to became subject to workman's compensation laws of.California." Contractor's hiring or sub-contracting signature certifies the following: I ce'r@i that in the_per#ormance of the_work-for which-this.perinit-is issued;'I4shall-employ persons subject to workman's compensa- tion laws-of California.' The applicant must calxfocall required inspections. Complete drawing on reverse side. _ Signed X �.0 - - Title:, Date: 3 1 1 I *, FOR DEPARTMENT USE ONLY Application Accepted by /i- Date �3 Al i �~ AreaAA jPit or Grout Inspection by Date' Final Inspection by = el Date Additional Comments: `' wa l ❑ Stk 466-6781 ❑ Lodi 369-3621 EI'Manteca 823-7104 0"Tracy .,8356385 1, Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 c , ' IFEE NF AMO NT DUE AMOUNT REMITTED CK RECEIVED BY D E PERMIT'NO. t f a.EH 13-24(FIEV.t/H51s EH 14-26 i 1�!