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APPLICATION FOR PERMIT +' SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES TYEAR 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 unty Ordinance No.549 for sewage or No. 1862 for watpump and the Rules and Regulations of the San Joaquin made in compliance with San Joaquin Cor Local Health District. �— L �l p J` c k -C3 31 L Aj ' i 0 Lot Size © A C PM � City •, Job Address Owner's Name C . Address 17-�-� C7�f ��f 7Be�fes. Phone� ._S 97 I lEtk' License No. x _ c . . . I� 7"! t }y] /o. Address ,Ot' O sw i'Contracior�OaC'r� Il C TYPE OF WELLIPUIIAP: "NEW WEl_L`106— W-'WELL'REPLACEMENT ❑j - DESTRUCTION ❑PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑DISTANCE TO NEAREST: SEPTICTANK SEWER LINES 'DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELLOTHER WELL PITSISUMPINTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS. Dia- of Well Ca❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavaation Type of Casing �� Specifications Domestic/Private p0ravel Pack " ❑ Tracy O Type of Groutl�C 4Ce- M Public F1 Other Cl Delta Depth of Grout Seal I I Irrigation Approx. Depth I 1 Eastern Surface Seal Installed by State Work Done _ Repair Work Done El Type of Pump H.P. sJ 1Nell Destruction ❑ Well Diameter Sealing Material Stop 501 + Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION I'i REPAIR/ADDITION I 1 DESTRUCTION I i INo sbptic system ithin m0 per-femitted if public sewer is l installation will serve: Residence Commercial— Other [ Number of living units: Number of bedrooms ° ah '.Character of soil to a depth of 3 feet' g Water table depth I N,-- - - Capacity ' No. Compartments SEPTIC TANK ❑ Type/Mfg C' ire, Method'of Disposal PKG. TREATMENT PLT. ❑ �7f 1 Distance to nearest: Wel!i Foundation Property Line, LEACHING LINE ❑ No. & Length of lines `" ` * Total length/size Line FILTER FILTER BED ❑ Distance to nearest:3 y Well - .;Foundation Property SEEPAGE PITS 11 Depth Size � §� Number � ❑ Distance to nearest: Well Foundation 7 Property Line t SUMPS ,_...�._. VC ,. DISPOSAL PONDS ❑ 1._�r ` E I hereby certify that I have prepared this application and that the work will be done sn accordance with San Joaquin county ordinances, state laws, and I rules and regulations of the'San Joaquin Local Health District.;,r Ik Home owner or licensed agent's signature certifies the following: "I certify that in tha_performance of the work for which this permit is issued, 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 r 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." x The applic st call for all required ins ctions. Complete drawing on reverse side. -� Title: Dare: 7` d Signed 7X p FOR DEPARTMENT USE ONLY Date 'Z-�` Area Application Accepted by 4 - % Date Pit or Grout Inspection by Date Final lnspectior%by Additional Comments: r ❑ Tracy 835-6385 ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 623-7104 ironmerital Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 Applicant - Return all copies to: EnvF R -_...� ria..-....-_... CK FEE_ AMOUNT DUE AMOUNT REMITTED E;3i RECEIVED l3Y DATE PERMITNO. INFOa EH 13-241REV.i/µ51 _ EH 14-26 L -----------