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r APPLICATION FOR PERMIT SAN JOAQUIN. OCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE.,. STOCKTON, CA i Telephone (209) 466-6781 I PERMIT EXPIRES 1 YEAR. FROM DATE ISSUED (Complete in Triplicate) e Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herei;,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. r yµ Job Address City Lot Size PM- Owner's Name Address 4L Girt -,(� / _ f Phone "v Contract / Com' Address Pp 4J� -W7 Z&Z License No �?�?aa Co Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ I DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE _ FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS —4 INTENDED USE TYPE OF WELD"", PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom -` ❑ Manteca Dia. of Well Excavation Dia. of Well Casing , ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material (top 509 Depth --F,,'lef'AMaterial (Below,50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ •REPAI /ADDITION 9 DESTRUCTION ❑ (No septics ystem permitted if public sewer is V' ` 1 `r - available within 200 feet.) Installation will serve': Residence T Commercial_ Other i Number of livingunits: ! Number of drooms rw Character of sail to a depth of 3 feet: Water table depth 13 SEPTIC TANK r'Type/Mfg 111C Capacity_ No. Compartments pal r PKG. TREATMENT PLT- ❑ ! Method of Disposal I ! 1 —Distance.to nearest: Well Foundation—Its Property Line AS ._ LEACHING LINE �&VLengtF'"of lines� � _® Total length/size 2�9 FILTER BED ID Dist ance�to nearest C77,Well _ 4r Foundation t r . Foundation __ f ��. Property Line ,L�_ i _i z , SEEPAGE PITS © Depth---� - .. Size t �=^=�- - ?_. : tNumber ` *+ SUMPS ❑ Distance to nearest; ��Well l Foundation -- 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. T- Home owner or licensed agent's signature certifies'tFe-following "I'certify that in the 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 certifies the following: "I certify that in the performance of the work-far which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." The applicant st call'for all r quir inspections. Complete drawing on reverste�idd Signed X Title: �9. 1, Date: �6 r FOR DEPARTMENT USE ONLY # ` Application Accepted by _ _ Date 4� r --Area- Z2, d Pit or Grout Inspection by 'Date `s Final lnsPe nib* Date hh A_dditi_o_nal Comments: _ _ _ ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Mante 823-7104 ❑ Tracy 635- 5 _ r Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Silk., CA 95201 FEE CK INFO AMOUNT DUE AMOUNT REMITTED '- ASH RECEIVED BY DATE PERMIT'N0. + EH 13-241REV. EH 14-28 Q♦ 1�d �/ ��Sit - O ..> �� .