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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE:.TON AVE., STOCKTON, CA Telephone 12051 438"8781 PERMIT EXPIRES ' YEAR FROM DATE ISSUED (Complete in Triplicate) Application Is hereby made to the San Joaquin Local Health District for a permit to construct end/or install the work heroin described.This application is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1882 for wall/pump and the Rules and Regulations of the San Joaquin Local Health District. Job AJdross L7`_5r � City -�+d-> Lot Size-L 1- PM C.m,er's Name Address .__ � - 'c Phone _ Contractor's Name •Yin License No. .� 5 Phone , } (1'FE OF WELL/PUMP: NEW WELL Li WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION O SYSTEM REPAIR D OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK _ SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION - AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL nROBLEMAREA CONSTRUCTION_SPECIFICATIONS U Industrial ❑ Open Bottom I ; Manteca Dia. of Well Excavation Dia.of Well Casing ❑ Domestic/Private n Gravel Pack ❑ Tracy Type of Casing --- SI,,w- rations ❑ Public ❑ Other C' Delta Depth of Grout Seal Type of Grout El Irrigation —Approx. Depth C Eastern Surface Seal Installed by - O Repair Work 'Done ❑ Type of Pump -.-__. - H.P. State Work Done Well Destruction C Well Diameter —_ Sraling Material (top 50'1 -- Npth_-- Filler Material f8elow 501 -_— TYPE OF SEPTIC WORE;: NEW INSTALLATION IG- HEPAIRiADDITiON Ll DESTRUCTION i_' (No septic system permitted it put,) sewer is �•� available within 200 feet.) rn i Installation will serve: Residence _-_ Commercial Other Numb*,of living units: _4-- Number of hedreiofn;�T_.- Character of wit to a depth of 3 feet: _ Water table depth _ — SEPTIC TANK 3--Type/Mfg Q_.111_ �M_ - Capacity_ V__" _- No. Compartments Z PKG. TREATMENT PLT.C � I Method of Disposal / Distance to nearest: Well Foundation L1 Property Line_3U1.- LEACHING LINE ('��No. 8 Length of linerTotal length/size _-L dtt-- FILTER BED C Distance to nearest: Well Foundation s-Q -__ Property Line ..lQ SEEPAGE PITS -- C: Depth J�_-___ . ..Size_ 1 L��_��1 mba►-- ---- SUMPS R''-Distance to rmresc Well_ _� Foundation Property Lina _ DISPOSAL PONDS I hereby certify that I have prepared this application and that the work will be done In accordance with San Joaquin county ordinances, state laws, and rules and regulations of the Sen Joaquin Local Health District. Home or+rw or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issuer:, I shall not empioV any person in such manner as to become subject to workman's o,)mpensation laws of Californ;e"Contractor's hiring or sub-contracting signature certifies%he'ollowing."I certify that in the performance of'the work for which this permit in issued,I shalt employ persons subject to workman's compensa- tion laws of Californic. The applicsn�lnu t callilifir.,all r)itiuired inspections. Complete drawing on reven!®side / Signed X.� - ------ Title: --..1�L� -�- - Date: p �1 e.. ------ -- / FOR DEPARTMENT USE ONLY / T f Application Accepted by � J'y % ( lL.�Y�-.___-.. _ _...- _--_.._---. Data_ � � Aroa_ Pit or Grout Inspection by Date ___.-__-.__ Final Inspection by- .f Date _ �v Additional Comments _ ----- -- -- --—- Sik 466 15781 l j-di 389 31521 C: Manteca 8237104 Tracy 835-6785 Applicant Return til copies to Environmental Hgatth Permit/Service% te01 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOt1NT RF-11-rD r'pCH RFCEIVED RV DATE FERMIT N0. INFO _ ---- --- .- rN t aFv ,o Li c: / L�jSsl, L1 i-1�•�.