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'i APPLICATION.FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 7601 E. HAZEL I ON AVE., STOCKTON, CA Telephone (209) 466_67gj" PERMIT EXPIRES i .YEAR FROM DATE ISSUED �� _ , i Xomplete 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. n - Job Ad dressa /�G fi.� ` y lf=�•. /~ i y City r Lot Size Owner's Name Address i - ,Phone _ . Contractor's Name License No. / .�� a,r �~ 5 TYPE OF WELL/PUM : Phone [ NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER 0- DISTANCE TO NEAREST: SEPTIC TANKS SEWER LINES DISPOSAL FLD.�C7d+_ PROP. LINE FOUNDATION AGRICULTURE WELLQL OTHER WELL �:�_ PITS/SUMPS rt . INTENDED USE TYPE OF WELL PROBLEM AREA-,-CONSTRUCTION SPECIFICATIONS'` Industrial ❑ Open Bottom ❑ Manteca Dia: of Well Excavation ._ ' , 4 Domestic/Private ❑ Gravel Pack T Dia. of Well Casing y ❑ Tracy ID Public Type of Casing _ Specifications ❑ Offer ❑ Delta DepthFgf•Grout Sea! - '~ - �' El Irrigation r .� ' Type of Grout /�2App ox. Depth ❑ Eastern Surface Seal Installed-by % Repair Work Done ❑ Type of Pump H.P. Well Destruction ❑ Well Diameter A n State Work Done ._ Sealing Material (top 50') fFl Depth ,FFifier Material(Below 50') TYPE OF SEPTIC WORK; NEW INSTALLATION Cl ,.REPAIR/ADDITION f� DESTRUCTION ❑ (No septic system permitted if public sewers /` available within 200 feet.} ` Installation will serve: Residence CommercialOth J Number of living units: Number of bedrooms,..- f Character of soil to a depth of 3 feet: -r SEPTIC TANK ,, f2 Type/k*g -. r Water table depth PKG. TREATMENT PLT. ❑ f Y .fi Capacity No. Compartments' Method of Disp al Distance,to nearest: Well Foundation Property Line ' A LEACHING LINE ❑r No. & Length of lines FILTER BED "� Total length/size r /Distance to'nearest: Well r'. + spy A Foundation Property Line ' SEEPAGE PITS " ,# C� Di3pth L Size Nri�i'ber`f .; SUMPS �` 'p D)stance-to nearest: .Well , 'z y DISPOSAL PONDS 'f❑f} a ` aaJ %l' Foundation r4 Property Line 3 I hereby certify that f have prepared this application and th rules and regulations of the San Joaquin Local Health Dist at at the work will be done in'accoidance with San Joaquin county ordinances, state laws, and Home owner or licensed agent's signature certifies the following: "I certify that in'the performance of the work for which this permit4 is issued,�I shahs not employ any person in such manner as to become subject to workman's comperisation laws of California."Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work for which this° rmit is issued, I shall em to tion laws of California." p y persons subject to workman's compensa- tion applica at II for,4 required in / plate drawing on revers 'side. Signed ' ` Title " ! Date: 0 a FO�Rr,DEPARTMENT USE NLY Application Accepted by \O-ACS-'(3 ;f !t Date Area CIE Pjf or Grout Inspection by a ��r�&'��5� ` cJ�� `j�_�`��, Date Final Inspection by Date Additional Comments: , ❑ Stk 466-6781 ❑ Lodi 309-3621- V Manfeca 823-7104 ❑Tracy 835-638.5 Applicant- Return all copies to: Environmental a ltK Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk.,-CA 95201 FEE a f y INFO AMOUNT DUE AMOUNT REMITTED RECEIVED BY �///{{� CASH DATE' PERMIT aNO � _ — +EH 13-24(REV.10193E �."-t.� —'� _uN REM �3t EH 13-29 U -