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I APPLICATION FOR PERMIT r SAN JOAQUIN LOCAL HEALTH DISTRICT 4 1601 E. HAZ-E'LiON�4,E:; STOCKTON, CA Telephone-{209M 466-6751 r PERMIT EXPIRES 1 YEAR FROM DATE ISSUED JUN 1 6 19$$ (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the workgy'ROMENTA�L HEALTH Zjlks+'MJoion is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and the Rules a I •o"F••t��t�`e'''$an Joaquin Local Health District. Job Address &A/12� ((�� �.�LL__ City Size PM � 91141, sz �Y S' Owner's Name Phone 6— i / L7 Contractor Gi[� .S Address�Q /'- License NoA0123 �CJ��O Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ / DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER ❑ 1 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES p DISPOSAL FLD. PROP. LINE 'f I FOUNDATION AGRICULTURE WELL. OTHER WELL PITS/SUMPS j INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ` LJ-Industrial ff Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private El Gravel Pack ❑ Tracy Type of Casing Specifications i i Public f 1 Other Ct Delta Depth of Grout Seal Type of Grout I Irrigation �_-Approx. Depth ISI Eastern Su ace Seal Installed by Fir Repair Work Done * Type of Pump _01416 H.P. State Work Done 11111111 , Well Destruction ❑ Well Diameter Sealing Material /top 50'J Depth # Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION l 1 REPAIR/ADDITION I DE ` i STRUCTION I k {Na septic system permitted if public sewer,isi'5 ' available within 200 feet.) Installation will serve: Residence t Commercial_ Other �; 1 Number of living units: Number of bedrooms / r 7 S i Character of soil to a depth of 3 feet:] i , Water tablefdeptvh + r SEPTIC TANK 0 Type/Mfg` I Capacity No. Comparll[Ants �:' f PKG. TREATMENT PLT. Llf ' Method of DispoA-I-N Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation ! . t Property Line , SEEPAGE PITS i I DepthSi -Size r Number / Z--' a t SUMPS I Ll Distance tp nearest: Well Foundation DISPOSAL PONDS Property Line t t I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances; state"I rules and regulations of the San Joaquin Local Health District. aws,and Home owner or li -ag s 099atur_,�e certifies the following: "I certify that in the performance of the work for which this em to an permit is issued, I shall not,a P y y pe on in such man er as to become subject`to' rkman's;compen"satiori laws oft California C6ntractor'shiring or sub-contracting signature certifiesthe f towing: "I certify t in the perf a h' ,work-for which,this'p6rmit is.issued;-I"%hall employ persons subject to workman's compensa tion laws o Califor 'a." Thea ppli r II requ' d i �rawing on r es ide. �1,�� 9 � Sined X 11 Title: 4.. Date: OR DEPARTMENT USE ONLY c .}- Application Accepted by Date Area Additional Comments: / �e -- _ Pit or Grout Inspection by Date Final Inspection by Dat ❑ Stk 466-6781 ❑ Lodi 369-3821 ❑ Manteca 8.23-7104 ❑ Tracy 935-6385 ' 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 CK INFO CASH "AECEIVED BY DATE PERMIT NO. ♦ EH1 -241REV.Iixsl ` — t EH 144.28 r