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{ APPLICATION FOR PERMIT i SAN JOAQUIN LOCAL HEALTH DISTRICT 1 1601 E. HAZE T QN AVE., STOCKTON, CA Telephone {20) 466-6781. .F ,.. ' ', n-- ' i- :moi-: ', . ;` ;� PERMIT EXPIRES 1 YEAR FROM DATE ISSUED„ {COmplete in Triplicate}: -w , 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. 1852 for well/pump and the Rules and Regulations of the San Joaquin Local Health District , r» , ;; rI Job Address - C1t Lat Size . . PM -- Owner's Name • r Nk AddressJ :�'�� .,_.Phone `may Contractors Name . ` L License No - Phone 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 .. rK a FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE FE OF WELL�'�PROBM AREA CON TRU 01 SPECIFICATIONS ElIndustrial '- - ❑ Open Bottom ❑ Manteca Dia.-of Well Excavation Dia. of Well Casing ❑ pomastic%Prvate ❑ Gravel Pack El Tracy Type of Casing Specifications ❑ Public / EI Other ❑ Delta Depth of Grout Seal 'Type of Grout - k' ! Y ❑ Irrigation t ---Approx. Depth -❑ Eastern Surface Seal Installed by Repair Work Done ` ❑ Type of Pump H.P.- State Work Done �� 5ealin Material (top 50') .Well Destruction C3, Well diameter g .'-'°" Depth Filler Material,Below 501 k TYPE OF SEPTIC WORK: NEW INSTALLATION EPAIR/ADDITION ❑ DESTRUCTION El (No-septic system pqrmitted H public sewer is available within 200 feet.) Installation will serve: Rest rice— Commi&cial 0�th`er Number of living units -Nurnber of bedrooms -� ! `Character of soil to a depth of 3 feet: Water table depth 9 SEPTIC TANK hype/Mfg t Capacity No. Compartments PKG. TREATMENT PUT. ❑ Method of Dispgsal Distance to nearest: Well foundation AAA Property Line 3 U i E ., 4 1 a r t � r,• .A i LEACHING LINE . I,W—No. i Length of lines�� T Total length/size t� Well Foundation - ==Property-L-ine-FILTER BED El Distance to nearest. SEEPAGE PITS ~'�&!Depth Size Number4- - 0 SU�PS� I j❑ 'Distance tv neatest: Well ,/ Foundation f Property Line DISPOSA"ONDS.--" ',E] v, ; - 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-afrthe San'Joaiuln 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 person in s EK ihanner'as to.become subject to workman's compensation laws of California."Contractor's hiring or sub contracting signature rt'rfies the;following:.'_'I.certity that in the performance work for which this permit is issued,I shall employ persons subject to workman's COM pensa-- - tion ifamia. '•---4- � r ' j/-,hie applica u call for I r fired in coon Co lete drawing,on averse std . I�n f% S Sign r tI Title: Date: r FOR DEPARTMENT USE ONLY Application Accepted by' Date �`-a-L3 Area vPit or Grout Inspection by A.- ' as Date Fina! Inspection �� ' by Additional Comments: r - ❑ Stk ,4664781 - Q Lodi 36&3e21 ❑ Manteca 8Z3-7104 0 Tracy 835 B�5 Applicant Return all copies to: Environmental Health Permit/Services 16D1 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 1FEE" AMOUNT IJUE'yAMOUNT REN1TTED C RECEIVED BY DATE PERMIT"NO.SH +EH 13241REV.10/831. ami .� h A"- ` 7 EN 1426