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~` APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH 131STRICT 1601 E. HAZELTON ON AVE., STOCKTON, CA Telephone (209) 466-67$1• l� 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 made in compliance with Sart 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. iS� J City Lot Size PM — Job Address_�� - .S, +Ethane Owner's Name JJC �j�Address \ Contractor — 65�/Address License No.Phone DESTRU TYPE OF WELL/PUMP; NEW WELL ❑ WELL REPLACEMENT E3CTION 171 _PUMP INSTALLAT In SYS TE P IR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK—(�6'�J SEWER LINES_ DISPOSAL FLD. PROP. LINE _ — FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE, TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing �Ondusfnal pen Bottom ❑ Manteca Ria. of Wall Excavation _ _Typo of Casin Specifications o stir/Private Gravel Pack ❑ Tracy g Type of Groutublic Other n Delta Depth of Grout Seal j I I Initiation Approx, Depth ( 1 Eastern Surface Saw Installed by of Pump H.P. , — State Work Done _.� Repair Work Done L] Type , Well Destruction ❑ Well Diameter, — Sealing Material (top 50 Depth a...- -= -•,_ FiNer Material (Below 501 — —^ TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION l I DESTRUCTION l I Nail bpelw Thin 200 feetc system tt'ed if public sewer is Installation will serve: Residence Commercial — Other -- Number of living units: ---LNumber of bedrooms Character of soil to -a depth of 3_feet: Water table depth — 0 TANK O t.❑ Type/Mfg _ �'�- t '° `�'-"�` ' Capacity ��- -_ No. Compartments _ Method of Disposal PKG- TREATMENT PLT.T1 s Distance'td nearest: Well Foundation Property Line Y-• r Total length/size t!i-- r LEACHING LINE 1 No. & Length of lines FILTER BED ❑•+ Distance to nearest: Well Foundation Property Line — SEEPAGE PITS Depth _ Size—.-. - NumNumbersz SUMPS L'1 Distance to nearest: Well 4 —0' Foundation Property Line 'DISPOSAL PONDS f�.^�"'--^ hereby certify that I have prepared this application and that the work thrill be done ir1 accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. Home owner or licenses agent's signature certifies the following: "I certify ance of the work far which this permit is issued, I shall not that in 'the perform employ any person in such manner as to become subject to workman's compensation laws of California." Contractors 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 m t call for all require inspections. Complete drawing on reverse lido. 3 Signed X Title: _— Date:: 'TMENT USE ONLY 1 Date �� 4—bArea Application Accepted by —, �__�..--G — Dato Final Inspection by Date Pit or Grout Inspection by y X /0) / SGrrn p �z 2 Additional Comments: �._ ❑ Stk 466-6781 ❑ Lodi 369.3621 ❑ Manteca 823-7104 ❑ Tracy 835.6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 .EH 13-24 (REV_ /115 EH 14-2a