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•l - } APPLICATION.FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., .STOCKTON, CA Telephone (209) 466-6781 C j PERMIT EXPIRES'1 YEAR FROM .DATE ISSUED ,. :IComplete-in;Triplicate). " :tests 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 District17 : a Wit Job Address " City Lot SizW_2 7 7 x PM i B SC 7. ` r - -- 5 '11 Owner's Name (Address A/Phone Contrac r Address Y�. � `License No.�F 9,12 s� Phon,`- + TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION LJ ' SYSTEM REPAIR!LJ 1F'r OTHER ❑ .. . y DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES' DISPOSAL FED i ! PROP. LINE E 0 FOUNDATION AG_RICU_LTURE,WELL � OTHER_<WELL PITS/SUMPS � INTENDED USE TYPE OF WELL PROLEM AREA CONSTRUCTION SPECIFICATIONS'~ ❑ Industrial ❑ Open Bottom ❑ Manteca. Dia,of Well Excavation Dia. of Well Casing O'Domestic/Private ❑ Gravel Pack ❑ Tracy Type of;Casing f Specifications ❑ Public ❑ Other []'Delta Depth of Grout Seal Type of Grout ❑ Irrigation --Approx. Depth ❑ Easte'rn Surface Seai-Installed by Repair Work Done ❑ Type of Pump H.P. > Sttate Work Done_ Well Destruction ❑ Well Diameter Sealing Material"(tap 501f'R _. i Depth Filler Material (Below 501 �1 TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ DESTRUCTION 1;'-INo septic system permitted if public sewer is *1availabletvi ithin 200 feet.) ;J Inst�allation will serve: Residence� Commercial_ ther .i [ Numb�,of living units Number o bedrooms . " Character of soil to a depth of 3 feet: ; Water table depth ; . SEPTIC TANK �TypelMfg # CapacityNo. Coripartments _ i f - PKG. TREATMENT PLT. ❑ } Method of Dispysai Distance to nearest: Welt.� Foundation ✓� Property Line._ } LEACHING LINE` { No. &'Length of lin s � iTi at I length/size o l FILTER.-BED r Ll Distance to nearest: Well�C) Foundatrbn,r'+�� Property Line SEEPAGE PITS ' Depth �S Size Number � I . a SUMPS ❑.'-Distance to nearest: Well !" Foundations Property Line DISPOSAL PONDS ❑ " I hereby certify that I have prepared this application an that tH�work will be done in accordance with Sari Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. Home owner or licensed agent's signature certifies the following, certify that in the performance of the work/for which this permit is issued, l shall not ' employ any person in such manner as-to`becohia iubject:to workman s compensation laws of California Contractors Hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued,I shall emplorsons subject to workman's compensa- tion laws of California." The applicant must call for all required inspections. Complete drawing on reverse side. f Signed X Title: _ li !` + Date: if FO�R D� EP�IP RTMENT USE ONLY Application Accepted by J Date !!! Area or Grout Inspection by /Date Final inspection by at 'F Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 -❑ Tracy 835-6385 f ---`-'A'pplicant'°—Return—&-copies to: EnGironmertal Healtf4 Permit/Services 1601 E—Hazelton Ave., P�-b.' Box 2009, Stk., CA 95201 F FEE INFQ AMOUNT DUE AMOUNT REMITTED CK CASH RECEIVED BY. " DATE PERMIT'NO. + EH 13-24(REVS/H5) � EH 14-26 ,