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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 s PERMIT EXPIRES TYEAR FROM DATE ISSUED �1 (Complete in Triplicate) l .. Application is haieby 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(or well/pump and the Rules and Regulations of the San Joaquin Local'Health District. Job Address �d.�1 r eY City L Lot Size /L� PM Owner's Name /4057— dg Address �` `` / �F'- 7� Phone y r Contractor ,L Y Z/, C R,_Address RZ-)s �� j7Ci/� License WA� Phone " TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ i PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ 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 0 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing I ❑ Domestic/Private �.�.��Ti-ravel Pack D Tracy Type of Casing � Specifications rl Public n Other Cl Delta Depth of Grout Seal Type of Grout ; I I Irrigation_.___....--_Approx. Depth .....I_I.Eastern_-._-_Surface.Seal Installed by _ Replair Work Done ❑ Type of.Pump H.P. State Work Done Well Destruction O Well Diameter Sealing Mate7i4l`Itop-501 ? Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: 'NEW INSTALLATION ." .REPAIR/ADDITION l 1 DESTRUCTION l I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence L Commercial, Other _ -,Y.. .,,�-•' •� ____ Numliei of living"units: �_ Number,of bed?oo,4.�..+�, c6acter of soil to a depth of 3 feet: A,1> _.__ _ Water table depth SEPTIC TANK ❑ Type/Mfg �..�� Capacity No. Compartments ______.,..__.. PKC. TREATMENT PLT. ❑ ��,��C�" Method of Disposal j Distance to nearest: Well/ Foundation s Property Line 7� LEACHING LINE 1`00 No.& Length of lines Total length/size OAF i j FILI1IER BED i•Y4 Distance to nearest: Well/�0�� Foundation< �F Property Line SEEPAGE PITS 3 1 1 De6t11Size Number SUMPS L l Distance to'nearest: Well Foundation Property tine DISPOSAL PONDS Cl 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 rulesr and regulations of the San Joaquin Local Health District. _ Home owner or licensed agent's signature certifies the fotlowing:�'I certify that in the performance of the work for which this permit is issued,1 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 'certifies the following:"JI certify that in the perforinance of the vuork forwhich this permit is issued,1 shall employ persons subject to workman's compensa tionilaws of California."i The lapplicant must call for 911 requir inspect-tons. Complete drawing on reverse"side. Sign ad X �' % Witte: l Date: ijAr DEPARTMENT•YJSE ONLY Application Accepted by l Pit or Grout Inspection by Date Final Inspection-by A'dd'itional Comments: l J w= ❑ Stk 466.6781 L7 Lodi 369-3621 ❑ Manteca BM-7104 © Tracy 835-6385 j Applicant- Return all copies to: Environmental Health Permit/Services 1601 E.!Hazelton Ave., P.O.Box 2009,-S2k., CA 95201_-� . V } INFO "�AMOUNT-DUE_ AM'OtJN�REMITTED. +-A t RECEIVED-BY �-- DATES---—PERMI7 NO- �. _. a.EH 13.24 IREV. EH 1426