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- d APPLICATION FOR PERMIT , SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA ! Telephone (209) 466-6781 f 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 _ Lot Size ��'� PM Owner's Name 1' 'v, "'"�' "''- Address APhone e Contractor's Name �` y License No. Phone wF_17Y 35 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT G DESTRUCTION ❑ f PUMP INSTALLATION ❑ `\ SYSTEM REPAIR El OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK. SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS �� INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial D Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing D Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing _ Specifications „ ❑ Public ❑ Other ❑ Delta ': Depth of Grout Seal Type of Grout 1 ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by J Repair Work Done ❑ Type of Pump H.P. 1 State Work Done 4 -J Well Destruction Q Well Diameter j Sealing Material (top 50') 13 Depth Filler,Material (Below 50 TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is 1 available within 200 feet.) Installation will serve: Residence—4--Commercial_ ,Other �+ Number of living units: Number roo of ms F 1 Character of soil to a depth of 3 feet: z, Water table.depth n, x SEPTIC TANK Er'-_Type/Mfg Capacity 01 No. Compartments PKG. TREATMENT PLT. ❑ ( Method of Disposal f Distance to nearest:'"' Well �J Property Line cm LEACHING LINE IYNo. & Length of linesr (FO ,,ee,�T��otal length/size FILTER BED El Distance to nearest: Well Foundation� 'Property Line r9m0d f I 1 _ SEEPAGE PITS ]--Depth Size— Number 3 g__ SUMPS ❑ Distance to nearest: Well 125 Foundation Property tine DISPOSAL PONDS ❑ I 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. t J Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall"F"'Si t--, :,,I 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 perforfnance.of the work for which this permit is issued,I shall employ persons subject to workman's compensa- tion laws of California." { The applicant must call f all re uired inspections. Complete drawing ori reverse side . Titls:_/�`�-sy'`-"� Date: Signed , _ _ it ,FOR DEPARTMENT USE ONLY Application Accepted by Date 0 z Area Pi r Grout inspection by Date f Final-Inspection by , Date Additional Comments: ° ❑ Stk' 466-&781' ' El-Lodi'•'369-3621—❑-Manteca—823-7104—O-Tracy-83543M Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE 1 AMOUNT REMITTED CASH 'RECEIVED BY DATE PERMIT'NO. i INFO + EH 1324[REV.10/831 F - "�(�H � 2A EH W26 Lis,..