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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE.,. STOCKTON, CAS Telephohe (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to the SanlJoaquin 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 _:n)5. IJ P¢( i�O City 10109,441 E2�Lot Size PM Owner's Name 7Z Al bl Address "Y]in S L p � Phone t� p Contractor F — Address - 7 e d l�9 A/l%[� 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 FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS x INTENDED USE TYPE Ol�WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia.,of Well Excavation Dia. of Well Casing ❑ Domestic/Private Ll Gravel Pack ❑ Tracy Type of Casing Specifications - 4 " e 1-1 Public F1 Other F1 Delta Depth of Grout Seal Type of Grout I 1 Irrigation —.Approx. Depth I I Eastern Surface Seal Installed by t Repair Work Done ❑ Type of Pump H.P. l` State Work Done_ Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth 'Filler Material IBelow 501 E TYPE OF SEPTIC WORK: NEW INSTALLATION i 1 REPAIR/ADDITION DESTRUCTION [ I (No septic system permitted if public sewer is -,a„".... available within 200 feet.).-, Installation will serve: .Residence_Commercial_ Other Number of living units: Number of bedrooms Character of soil to.a depth of 3 feet: / �- x Water table depth SEPTIC TANK 171Type/Mfg 4_ J,/ Capacity No. Compartments PKG. TREATMENT PLT. ❑ # G /' Method of Disposal Distance! Foundation to nearest: Well .~ ( — Property Line LEACHING LINECINo. & Length,of fines "" f 1011 VTotal length/size F. FILTER BED Dlstance-tt>nearest: Well /�T Foundatiorf" �r7--"""•pfa--F y Line SEEPAGE PITS I I Depth A 'size Number n' SUMPS U Distance to nearest: Well Founclatiori A Property Line r^" 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__- .... - 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 not employ any person4t such manner as to become subject to workman's compensation laws of California." Contractbr s hiring or sub-contracting signature ` 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." The applicant must call fo all required'ins *tions. Complete drawing on reverse side Signed X�- { m Title: Date: c I DEPARTMENT USE ONLY ' Application Accepted by r Date � J�� Area .% .j / vzPit or Grout Inspection'by �. ""' - Date �'Final Inspection by J Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi` 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6365 Applicant- Return all copiestto: Environmental Health Permit/Services 1601 E.'Hazelton Ave , P.O. Box 2009;-S''CA 95201 FEE. E— EH ^ � CK -- MOUNT DE _ MOUNT.RMITTED �.E.�CE�IV.-eD CASH+_ ' DATE PERMITNO,•- +rEH13-24INEV.t/K51 .. 14-26 +