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i APPLICATION FOR PERMIT i SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR-FROM DATE ISSUED {Complete in Triplicate) 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 District. Job Address 6-Z ' 7 c� City Lot Size PM a! �'l� �L Address = rPhone---- -- - -Owner's Name a �� , ContractaEE GG. Address!. C'C �! c �� ``�``t-License NI.T _Y-2_74_ Phone36¢ --'G 0 - T-Y.PE-OF WELL/P_UMP:,—.,r„_______.,,,NEWWELL_❑_WELL REPLACEMENT_ d_,.,,,�,—DESTRUC710N_l7_� PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ t OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER.LINES\ 1- DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTOREELL"k y -V11OTHER WELL PITS/-SUMPS.-__ . INTENDED USE TYPE OF WELL. PROBLEM AREA CONSTRUCTION:SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other n—O-Delta—Depth of Grout Seal r-� ,Type of Grout ` ❑ Irrigation ---Approx. Depth ❑ Eastern:, Surface Seal Installed.'by Repair Work Done ❑ Type of Pump I H.P.: ' . j tate Work Done I Well Destruction ❑ Well Diameter t Sealing Material (top 501 3 Depth `- ')ler;Material (Below 501 ' [� TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAI /ADVTION DESTRUCTION (No septic system permitted if public sewer is ' available within 200 feet.) v Installation will,serve esidence 7!! Commercial Other Number of living units: / Number of= dYooms Character of soil to a depth of_3 feet,'` '� Water table depth _- SEPTIC 74NK _-'7j�Type/Mfg Capacity d No. Compartments PKG. TREATMENT PL-Tri S Method of pisposal Distance'�' to:nearest:. Well Foundation�_�.— Property Lin.2 LEACHING LINE 5-Y lvo. & Length of lines 12 `- Total length/size- FILTER ength/size FILTER BED ❑ Distance to nearest: Well Foundation�ILIQ Property Line ._,__ SEEPAGE PITS ❑ epth Size "�! Number j SUMPS p Distance o nearest: Well .._-.. Foundation�// Property Line_ ! DISPOSAL PONDS ❑ 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 San Joaquin Local Health District. r Home owner or licensed agent's signature certifies the following; I certifythat in the .rformance of the work for which this permit is issued, I shall not 9 9 g. „ pe. employ any person in such manner as to become subject to workman's compensation laws of•California." Contractor's 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 employ persons subject to workman's compensa- tion laws of California." I The applicant Rallll req ' d ' spe ions. Complete drawing on reverseSigned Title: Da#e,—FOR DEPARTMENT USE ONLY Application Accepted by " Date Area P it or rout Inspection by Date Adj4tn!S_�SFinal Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy `8355-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. -Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT"NO. INFO + EH 13-24(REV.1/s 5) S, o o EH 1426 f