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APPLICATION FOR PER 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) : 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. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address _ c�}�—�r{/7 City Lot' Size 0 x I00 PM Q 7 Owner's Name r "✓''`�� ^Address • Phone q�/-1 F G + i S Contractor's Name , License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ , PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER C1 `— %,..•R, " DISTANCE TO NEAREST: SEPTIC TANK 1 SEWER LINES\, DISPOSAL FLD. PROP. LINE FOUNDATION "AGRICULTURE WELL. OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private O,Gravel Pack ❑ Tracy Type of Casing. ! Specifications (C ❑ Public 4❑ Other ❑ Delta Depth of Grout Seal _ Type of Grout Q Irrigation q + --L-Approx. Depth ❑ Eastern Surface Seal Installed by l/1 Repair Work Done ❑ 4 Type of Pump, H.P. -State Work Done J,, Well Destruction 1-1Well Diameter # V *'y§gylind"Material (top,50') pe Oh ._,. fi Filler M terial (Below TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION DESTRUCTION ❑ (No septic'system permitted if public sewer is available within 200 feet.) ' Installation will serve: Residence-k-__Commercial_ Other- Number of living units:-__j_ Numbe01 r of bedrooms I" ` a �" Character of-soil to-a-depth`of-3 feet:-Ia_ T ' - "`" 4 "Water table depth 0 SEPTIC TANK ❑ Type/Mfg i-W-i It Capacty No. Compartments M PKG. TREATMENT PLT1 EIt Method of Disposal Distance to nearest: Well'""* '-'Foundation �j ' Property Line LEACHING LINE ❑ No. & Length of lines 1 r "Total length/size FILTER BED i❑ Distance to nearest: Well — Foundation 5 Property tine + 1 (. Z Number } SEEPAGE PITS Depth S Size SUMPS c❑ " Distance"to nearest: Well Foundation f0+ Property tine ;-� .f DISPOSALPONDS rt 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 the following: "kcartify 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 compensavoi n 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 compensa- tion laws of California." The applicant must call fo all re d ins tions. Complete drawing on reverse side. t t `i Date: Z. .Signed l Q DEPARTMENT USE ONLY I Application Accepted by - ' "' " Date S 2,) Area Pit or Grout Inspection by bate 1Z_ Final Inspection by Date A ditional Comments: J ak yt a tl"s" �' — St 4f6 6781 Lodi 369- 1 ❑ Manteca 823-7104 q ❑Tracy 83rr6385 ' //App``licant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 20091 Stk., CA 95201 IFEE NFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT"NO." ; + EH 13.24MEV.10/631 EH 14-26 a �