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APPLICATION FOR PERMIT V SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED' (Complete in Triplicate) k Application is heteby 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. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. 1 1QV 1y/ SI HHr E , o /'� Job Address r�� s City Lot Size PM + Owner's Names s MPhone + W /)' Contractor4-y s ense No. hone TYPE OF WELL/PUMP: _k NEW WELL ❑ WELL REPLACEMENT ❑ C DESTRUCTION PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST:,SEPTIC TANK SEWER LINES` DISPOSAL FLD. PROP. LINE _ FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS V, INTENDED USE # TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS !^�� 0 Industrial 1 ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private t ❑ Gravel Pack' ;». ❑ Tracy - Type of Casing tSpecifications ❑ Public { Ll Other ❑ Delta 4'Depth of Grout Seal _ Type of Grout _ I I Irrigation _Approx. Depth I 1 Eastern Surface Seal Installed by I" Repair Work Done ❑ , Type of PumF p ' H.P. - State Work Done Well Destructionr P ❑ Well Diameter iSealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION Ppr REPAIR/ADDITION f I DESTRUCTION I I (No septic system permitted it public sewer is available within 200 feet.) Installation will serve: Residence I Commercial Other a Number of living units: Number of bedrooms r x Character of soil to a depth of 3 feet: Water table depth A. SEPTIC TANK ❑ T e/Mf YP 9 INA Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal ti Distance to nearest: Wel m Foundation k Property Line , LEACHING LINE No. & Length of lines ` Total length/size79 FILTER BED ❑ Distance to nearest: Well -. Foundation 11 - Property Line- -4 r. , SEEPAGE PITS 11 Depth Size Numbe`r's" SUMPS Cl distance to nearest: Well!(A+ Foundation Property Line + ~ DISPOSAL PONDS ❑ a E 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. .4 Home owner or licensed agent's signat6re.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 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 for which this permit is issuedr I shall employ persons subject to workman's compensa- tion laws of California." The applicant m cal all qui ed in c ons Complete raWi' ori er side. a _ Signed X Title: / S ' Date: FOR DEPARTMENT USE ONLY Application Accepted *by : Date _ Area Pit or Grout Inspection Date 5-7-1-4--7 Final Inspection b Dates 2- Additional 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 CK 4 INFO AMOUNT DUE . AMOUNT REMITTED CASH r RECEIVED BY s DATE PERMIT'NO. + EH T3-241REV.t/H51 Q�1 / i� EH 1426 f�7 J