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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT J 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. Telephone (209) 466-6781 DATE ISSUED PERMIT EXPIRES 1 YEAR FROM DATE ISSUED k (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 µ 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 4e lations of the-San Joaquin Local Health District. Job Address .7a`�°' Subdivision Name Owner's Name LL Address Phone Contractor's Name ( License No. Phone TYPE OF WELL/PUMP WORK: NEW WELL ❑M 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 { k INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS,-, i ❑ Industrial ❑Open Bottom ❑ Manteca', Dia, o 'Well Excavation Domestic/Private ❑ ❑ Y �' Dia: of Well Casing l r� fe Gravel Pack Tracy ,. 9 ❑ Public ❑ Other ❑ Delta ;t, -Type of Casing ❑ Irrigation Approx. ❑ Eastern Specifications Cathodic Protection Depth I ❑ tiDepth of Grout Seal Geophysical n — (� P y rti sical Type of Grout - ❑Other w t rt Surface Seal Installed by J Repair Work Oone ❑ Type of Pump H.P. 'L State Work Dane Well Destruction ❑ Well Diameter Sealing Material '(top 50') i Depth Filler Material (Below 501) 4, TYPE OF SEPTIC WORK: NEW jINSTALLATION REPAIR/ADDITION ❑ (No septic dank or seepage pit permitted if public sewer is available within 200 feet.) Installation will serve: Residence` Commercial _ Other _. .!j Number of living units: �_ Number of bedrooms Lot size rr Y �4� ISI Character of soil to a depth of 3 feet: /Water table depth M SEPTIC TANK E] rType/Mfg ��i�i Capacity No. Compartments 7 +.K&--TR ATMENT PLT. Disposal Type/Mfg �,�,(� ,(/FT Ski Tt0" Capacity Method of M h SEWAGE SYSTEM ('Distance to nearest: Well.., Foundation ". rProperty Line s DESTRUCTION ❑ # _t L r� - i LEACHING LINE 'No. & Length of limes.-.ts i Total length/size FILTER BED 4Distance to nearest: Well -Foundation'.-- Property Line n Number SEEPAGE PITS ❑ ::,Depth Size - . SUMPS ❑ Distance to nearest: Well ,.Foundation- Property Line l DISPOSAL PONOS ❑ 'NSTiJ �,�� .��,�� :'f�� I hereby certify that I have prepared this application and that the workkwill be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations,of,the_San Joaquin,Lgcal Health District. "'Home owner or licensed agent's+s%'gnature certifies the following: "I certify that in the performance of the work for which this permiL'is issued, I shall,not employ anyY.pe Fson in-such mannerxas,to becomersubject to workmans compensation laws of California." Contractor'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 compensation laws of California." The applicant must cal nr re - d inspections. Complete drawing on •reverse side. `€ Signed"X _ `"""Tifle: F4 EPARTMENT USE ONLY Application Accepted by Area _ E] Stk f', 466-6781,'.-e t I Additional Comments: ¢.. ❑ Lodi 369-3621• l .Pit or Grout Inspection by -" ate �• •,4'�-'. anteca_823 7104 -� j ,_ t r Final Inspection;by Date ;"� ,;/ tv- ❑;Tracyt 835-635 Applicant - Return all copies to: Environmen ealth'Permit/Services 1601 E.-Hazelton Ave., P.O. Box 2009, Stk CA 95201 ` " 3u FEE BASE yAMOUNT DUE AMOUNT REMITTED RECEIVED BY ' DATE k PERMIT NO'.` INFO •� - .-•`- _ . 10782"500 'yam EH 13-24 RE=V. 10 82 � + f , 14-26 i _ j .