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x APPLICATION FOR PERMIT �q^_;-3 SAN JOAQUIN LOCAL HEALTH DISTRICT R, 1-/131 1601 E. HAZELTON AVE.,:.STOCKTON, CA Telephone (209) 466-6781 " " PERMIT EXPIRES TYEAR FROM DATE,.ISSUED ` (Complete in Triplicate) y 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 ist . 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'J oaquin%I LocalHealth District. e� G C E " o o L Al Ciity z�Job Address Lot Size PM `fes d�i�_ 7 e =- Owner's Name Address.. P Phone a� Address p7 License Contractor -!i # , TYPE OF WELL/PUMP: NEW WELL Ll WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP-INSTALLATION❑-�--SYSTEM-REPAIR-E] �. OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK ,'SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION 'AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WtL-L7 'PROBL:EM; REX--i—CONSTRUCTI'ON--SPECiFICATiONS— ❑ Industrial.I L1 Open Bottom ❑ Manteca Dia•. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications a« -- T e of-Grout � -a- (1 Public ❑ Other - ❑ Delta Depth o1 Grout Seal yp ' .. . I I Irrigation _.-Approx. Depth l I Eastern Surface Sea! Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done + Well Destruction ❑ Well Diameter Sealing Material (top 50'1 ' Depth Filler Material (Balow 50'1 1 t TYPE OF SEPTIC WORK: NEW,INSTALLATION REPAiWADDITION 1.1 DESTRUCTION 4�4-1No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence A Commercial S , , ther Number of living units: A_ Number of bedrooms f� %lJ - Water table depth _¢ Character of soil to a depol"3 feet: - lNo. Compartments SEPTIC TAMC 1 ❑ Type/Mfg 4 Capacity �' r PKG. TREATMENT PLT. ❑ Method of Disposal C' I Distance to nearest: Well'" lid Foundation Property.Line�- — a' Total I n th/size LEACHING LINE Cl ,Nofi,& Lerigth?of Ines r / 9 r FILTER BED ❑- Diatance to nearest: yWellf_ �Foundation =Property Line 1 I c r _ SEEPAGE PITS i I Dept' 4 ` Size —a Number SUMPS # L1 Distance, nearest: Well t -rFounda4io� _Property Line i DISPOSAL PONDS r LD - hereby certify that I have prepared this application.and-tFia'f-the work will be done in accordance with San Joaquin c6unty ordinances, state laws, and rules and regulations of the San Joaquin Local Health-Di?;trict..' r Home owner or licensed agent's signature certifies the following: " certify that in the performance of the work for which this permit is issu#d, I shall not n employ any person in such manner as to become subject to workman's compensation laws of CaGtornia."Contractor's hiring or subcontracting signature certifie's the following: "I certify that in the performance-of the work for which this permit is issued'A shall employ persons subject to workmap's compensa- (.. tion laws of Galifornia. The applicant tali o all re ire rns ion Complate_drawirig on rev-�! Qerse"side"'' - eV , ' �q • I� Signed X Title:- Date: e tr FOR DEPARTMENT Usi ONLY r. Application Accepted by ` rDte / Area i d Y� it Grout Inspection by��, D e � � Final Inspection by T' Additional Comments:• ❑ Stk 466.6781 ❑ Lodi'369-3621 O Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 r FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT IVO. INFO +.EH 13.24/REV.t/H 51 ,- �� ..�� � -24 09 -� EH 14-26 t