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APPLICATION FOR PERMIT T2 ( SAN JOAQUIN LOCAL HEALTH DISTRICT 11.11 1601 E. HAZELTON AVE., STOCKTON, CA � �S �^ Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED okll (Complete in Triplicate) �U Application is hereby made to the San Joaquin Local Heatth District for a permit to construct and/or install the work herein described. This application s�3 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. $ Job Address �TS City t Size ASS PM i Owners Name e /AddressPhone '7�l Contractor's Name ., ` N License No. C7;�y3 __ _ Phone TYPE OF WELL/PUMP: NEW,WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ f _. PUMP INSTALLATION ❑ ':. SYSTEM REPAIR ';OTHER •1] DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD_. PROP. LINE } ' FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS" Ll Industrial ❑ Open Bottom ❑ Manteca Dia. of Wel! Excavation Dia. of Well Casing ~ ❑ Domestic/Private ❑ Gravel Peck ❑ Tracy Type of Casing Specifications W ❑Public Y ❑ Other C Delta Depth of Grout Seel Type of Grout Irrigation ---Approx. Depth C Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. _—_ State Work Done Well Destruction . ❑_ Well Diameter Sealing Material (top 50'1 Depth r Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATIO REPAIR/ADDITION C DESTRUCTION C (No septic sysiem permitted if public sewer is z' available-within 2W feet.) G Installation will serve: Residence-X Commercial Other Number of living units: __/_ Number of bedrooms !E5 — / Character of soil to a depth of 3 feet: __Water table'depth SEPTIdTANK Type/Mfg Capacity No. Compartments 7— PKG.FTREATMENT PLT. ❑ ti f1 Method of Dispose Distance tomnearest: Well Foundations Property-Line _?_ W _ LEACHING LINE No. & Length of lines �-Total length/size FILTER BED 0 Distance to nearest: We 11 c>1_42P r Foundation af�22 f Property Line_ � �• SEEPAGE PITS ❑ Depth Size Number } SUMPSf ] Distance to nearest: Well Foundation~ _� Property Line DISPOSAL PONDS ❑ n, I hereby certify that I have prepared this application and that thework will be done in accordance with San Joaquin county`ofdinancea,state laws, and rules and regulations of the San Joaquin Local Health District. ^' Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for Which this pemtit is issued,'l shall not emptAfiofloon ' ch manner as to become subject to workman's compensation laws of Cal'rforra."Contractor's hiring or sub-contracting signature certificertify that in the performance of the work for which this ermit is issued, i shall employ pesons subject to workman's compensa- tion lThe aor al uired ' s t' s. om to drawing o rev sidSigneTrue: Date: _ i FOR DEPARTMENT USE ONLY - Application Accepted by ' Date J" Area — w �Pit.or Grout.Inspection by--,— - - Date Final Inspection byT - - -�Date ' i _ - Additional Comments: �"'• � '" ' - _ E] Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 _ Applicant- Retum all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 952FEE 01 INFO AMOUNT DUE AMOUNT REMITTED CK CASH RECEIVED BY DATE PERMIT NO. H 111425 3-26(REV. 10fe3i 7 EH �--5 S• o 0 7 3J%" �J-1 $L3 E i