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APPLICATION_ FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT k 1601 E. HAZEL T ON fAVE.,"STOCKTON, CA Telephone 12091 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplic ate) 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/ and the Ryles and Regulations of the San Joaquin Local Health District, -V� ..� {- - S Job Address ` City Lot Size a PM t � 3 Owner's Name _04. 494J. -Address 1V OW. Phone 9 r Contractor2.4- 41 rV!*1 S EL Address I��W � License No. Phone TYPE OF WELL/PUMP: NEW WELL,L] t` WELL REPLACEMENT ❑ DESTRUCTION ❑ + PUMP INSTALLATIONw� SYSTEM REPAIR ❑ Q.T,FiERt❑ 4.1 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. __ PROP.`j�INE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS I l' INTEN�EQ U5E TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS r j ©`Indusieial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation ' Dia. of Well Casing �j 1 stic/Private ❑ Gravel Pack ❑ Tracy Ty ❑ Dorrlepe of Casing— -. r Specifications Jt ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation —Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump IT.P. State Work Done e ii Well Destruction ❑ Well Diameter Sealing Material(top 50') E Depth 1 Filler Material (Below 50') a TYPEOF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION DESTRU_CTION,❑ [No septic system permitted if.public sewer is j avaifd a within 200 feet.I1 t Installation'4 wlll serve: Residence�t Commercial_ Other #Q, Number;ofrhvrng units: Number ofterlrooil .7 e l l a 'Character of soil to a"depth of 3 feet: r ,fJ� _ Cr.0 _ _ _ _ _ _Water table depth `� " ! t �" :SEPT-dC TANK_,: Type/Mfg,_r — J CIF " Capacity I _ No. Compartments I S ' @ 4 i 9 I PKGTREATMENT PLT'. 171! � / Method of Disposal ri _ T�COi Lance o nearest: Well ©D Foundation Property Line__ Ad LEACHING LINE No. & Leng h ofs lines Total length/size l t FILTER BED l ❑ Distance to nearest : Well AV Foundation—,W Property Line_ `SEEPAGE ITS '�-' ❑��Depth Size" Number ff 1 f -d is".I. a. - Y" t SUMPS :D�1D�tance,t�onearest: Well Foun_tlatron .Property Line e}ra I DISPOSAL PONDS r -r I hereby certify that I have prepared this- Pik,application and k the woek,will•befdone�in:accordance`with-Sen Joaquin-county-Joaquin ;st nCdgate laws, and rules and regulations of the San Joaquin Lotal(Health biistrict. HJme.owner or licensed agent's signature ce6fies thelollowing: "I certify that in the performance of the work for which this permit is issued, I shall not I "'employ any,person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contractirig signature certifies i—i--!low' "I certify that in the performance'of the work for which this permit is issued,I shall employ persons subject to workman's compensa tion laws of morn 3 E The ipplic "t"must li a!I required ins�e,,dctions. Complete drawing �re�ide, ' Signed °` is y Title: Date: C DEPARTMENT USE ONLY t Application Acceptedby [�t�' AKDate �y Area Z� S yt/or Grout Inspection byi �'_ � Dat Final Inspection by Date d (J i Y i. _� Additional Comments: :-11 " t r° - f ❑ Stk 466-6781 D..Oodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 t q Applicant- Return all copies to: Environmental Health Permit/Services_ 1601 E. Hazelton Ave., P.O. Box 2009, �-tk., CA 96201 I FE41 E AMOUNT DUE rt AMOUNT REMITTED CK RE_CEIV_ED BY DA_E_ PERMIT'N_O. INFO.. La. -z CASH �. - - r + EH 13-241REV.7/851 `„' "a �� .'-R._ y, t,,�q4. r .- ._ - �:a,. V f` g d- —F6- �. �03/� EH 1426 3