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r APPLICATION FOR PERMIT 2,o SAN JOAQUIN'LOCAL'HEALTH DISTRICSCIONED 1601 E. HAZEL T ON AVE., STOCKTON, CA t Telephone (209) 466-6781 r PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District fora pe made rmit+to construct and/or install the work herein described.:This application is Loco! Health District.compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Ryles and Regulations of the San Joaquin T F Job Address i City Lot Size �- pM „ rz r-i � I Owner's'Name � � Address Phone- `�.✓, -,1' i i Vii �� .. i Contractor 4 License No. Phone S TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK " -�'�"""'""""' _.,.._._�,__._„ - -..._ ,- — -�--� SEWER LINES DISPOSAL FLD. PROP. LINE f ' FOUNDATION ( AGRICULTURE WELL OTHER WELL PiTS/SUMPS _ INTENDED USE TYPE OF WELLI PROBLEM A R ❑ industrial AREA CONSTAUCTiON SPECIFICATIONS ` r ❑ Open Bottom ❑-Manteca. Dia. of Well Excavation ElDomestic/'Private ❑ Gravel Pack:- '{f f Dia. of Well Casing ❑:Tracy � Type of Casing Specifications �. ❑ Public ' ❑ Other ❑ Delta I Depth of Grout Seal ❑ Irrigation Type of Grout g ---Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P - .- ---" -- w---- Well Destruction ❑ Well Diameter -.State Work Done Sealing Material Itop 50'1 • Depth Filler Material�IBelow 50') ..y r"`• I TYPE OF SEPTIC WORK: NEW INSTALLATION M—RrpAIR/ADDITION ❑ DESTRUCTION ❑ fNa septic system permitted if public sewer is I available within 200 feet.) Ins#allafion will serve: Residence✓ommercial— ther `Fp Number of living units: � Number of bedrooms --,- f Character of soil to a depth of 3 feet: L k F Water table depth SEPTIC TANK U--Type/Mfg j( �' i ��`� Capacit;= __ No. Compartments PKG. TREATMENT PLT. ❑ € F , � (� ,{ )I MethodofD' posai. Distance to nearest: Well Foundation moi'Property Line y f 1 LEACHING LINE �No.-& Length of linas -•- =Total length/size. FILTER BED i ❑ Distance to nearest: Well ' Foundhti�on -�r^ '+ 'x 1 �°pefi' Line � 1^' '.•d SEEPAGE PITS ❑ Depth Size � Number SUMPS ❑ Distance to nearest: Well Foundation DISPOSAL PONDS F1 .� Property Line a }. ... I hereby certify that I have prepared this application and that the work will be donein accordance with San 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::l-certify-that-in•the-performance•of the•work-for-which-this"permit-is-issi]ed-I-shall-not employ any person in such manner as to become subject to workman's compensation laws of-California.".,Contractor's hiring or sub-contracting signature certifi the following:" certify that in the performance of the work for which this permit is issued,1 shall en, to tion la f California." `p y persons subje_ctt_to workman's compensa- The applican s call for I req r d ins c ons o lets drawing on verse si e. / �`�� V� f.✓ / f Signe # Title: a® �� Date: FOR DEPARTMENT USE ONLY Application Acepted by Date Area Pit or Grout Inspection by Date Final Inspection by i Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835433% ` Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, 5tk., CA 85201 FEE AMOUNT DUE AMOUNT REMITTED K INFO C RECEIVED BY ._ DATE PERMIT NO. + EH 13-241REY.1/s 51 ��^ EH 1428 -q q s