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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT f 1601 E. HAZEL i ON AVE., .4 STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAWFROM DATE ISSUED 0 {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 Ryles and Regulations,of the San Joaquin , Local Health District. Job Address! City Lot Sizef PM Owner's Name �' 'Address tel. i �`-- Phone y i Contractor Address 1 z ��;�� License NoA �:Phone-T 0 TYPE OF WELL/PUMP: NEW WELL ❑. % WELL REPLACEMENT ❑F DESTRUCTION ❑ PUMP INSTALLATiON,G SYSTEM REPAIR ❑ OTHER ❑ t DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES _ DISPOSAL FLD. PROP.' LINE- FOUNDATION AGRICULT_URE.WEt L, OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AEA CONSTRUCTION SPECIFICATIONS r' ! ❑ Industrial ❑ Open Bottom--- "❑ Manteca 1 ,Dia. of Well Excavation Dia. of Well Casing E71Domestic/Private ❑�Gra�el Packs 11Tracy tType-of Casing Specifications l r❑ Public e ❑ Other ❑ Delta " N.,LLiDepthof Grout Seal Type of Grout ❑ Irrigation : Repair Work Done ❑ Type of Pump ' -` 1 >H.P. State Work Done,.• I WellDestruction ❑., Well Diameter Sealing Material (top 5011 �" ` i Depth Filler Material.(,,Below`50 "`i°4�-! -�.eT,YPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION DESTRUCTION ❑ (No septic system permitted if public sewer is 4 +! t p vailable within 200 feet.) Installation will serve: Residence_ Commercial Otherlft:f Y. i,Ta•'� r f . Number oflivingunits:-R-0 Number of bedrooms Character of soil to a_.depth of 3 feet;. �`-" 1/Vater table depth SEPTIC TANK ElType/Mfg rr - Capacity No. Compartments f PKG. TREATMENT PLT. ❑ �✓ �' Method of Disposal l d F Distance to nearest:.. ell. ounation Property Line �_ . LEACHING-INE- ❑ No. & Length of lines - Total length/size FILTER BED "'S L1Distance to nearest: Well Foundation f Property Liney SEEPAGE PITS Depth Size L11W '1__1.11"N'bmber_3_ SUMPS ❑ Distance to nearest: Well Foundation LgEf PropertyfLine DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work will berdone in accordance'with�Sari Joaquih county ordinances, state laws, and rules and regulations of.the-San Joaquin Local Health District. w Home owner or licensed agent's signature certifies the following: "I certify that-in the performance of the Werk"-for which this permit is issued, I shall not employ any person in such manner as to become subject to workman'scompensation laws of California." Contractors hiring or sub-contracting signature —,..certifies the following:"I certify that in the performance of the work for which this permit is issued, I s"hall employ persons subject to workman's compensa- tion,laws of California." xt f vq;� i i IrThe applicant must call for I requir inspections. Complete drawing on revers side. Q Signed `"-, Title:, '7"? - �. F� Date: r C kw '' FOR'DEP -RTMENT USE ONLY�.,,..•� ACt t Applicatlon'Accepted-by - Date Area I a `-, '- -4 "��-Pit o Grout Inspection by" —� "� Date - Final inspection by " Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7394'A f-k ❑ Tracy.Eb66385 Applicant- Return all copies to: Environmental.Health Permit/Services 1601 E:Hazelton Ave., P.O. Box 2009, Stk., CA 95201 l FEE AMOUNT DUE AMOUNT REMITTED CK# RECEIVED BY DATE PERMIT'NO. INFO CASH + EH1}24(REV.1/s 5) EH 1426 111 z