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APPLICATION FOR. PERMIT SAN JOAQUIN .LOCAL HEALTH DISTRICT ;-� 1601 E. HAZELTON AVE., STOCKTON, CA . Telephone (209) 466-6781 µ -� PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ► ,, -IComplete in Triplicate) I Application is hereby made•tthe San Joaquin IX Local Health District for a permit to construct and/or install the work herein described. This application is M 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.-,' Jab Address Ci - Lot Size Ci PM 1 i<� Address -� ^7 Phon l Owners Name Contractor { Address �' - f License No. Phone �t TYPE OF WELL/PUMP: NEW WELL E] WELL REPLACEMENT ❑ DESTRUCTION El r PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK 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 ❑ Gravel Pack C❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by — - - Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction El Well Diameter Sealing Material {top 5b']n _ Depth Filler Material Melow 501 -- _ TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION DESTRUCTION ❑ (No septic-system permitted if public sewer is available-within 200 feet.l - - _ Installation will serve Residence-X Comr'rieraal--Other- ` Number of living units: Number of bedrooms N Character of soil to a depth of'3 feet: - s0,,C� ° - Water table,depth SEPTIC TANK ❑ Type/Mfg 11_X Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation ` Property Line 1 . LEACHING LINE ( No. & Length of 11's -A- �V Total length/size © "� FILTER BEd ElDistance to nearest: We 1 ` Foundation 15 f Property Line ?$A- SEEPAGE PITS $L Depth ZS- Size 2i2✓ ! Number r- ;—�SUMPS�'�--- -" '` ff—Distance to nearest: - Well A- Foundation =Property Line'" DISPOSAL PONDS ❑ 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. 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 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 issued,I shall employ persons subject to workman's compensa- tion laws of California." The appli a t must call for all required inspections. Complete drawing on reverse side. Signed- Title: }tiyC,�\_ _ Date: FOR DEPARTMENT USE ONLY Application Accepted by Date Z-2 Area OrGrout Inspection byDate inal Inspection-by Da Grout Inspection by Additional Comments: _ ❑ Stk 466-6781 Lodi 369-3621 ❑ Nranteca 823-7104 ElTracy 8355-6385 �-�e, Applicant-•..Return�_all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.Q. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED I CK RECEIVED BY 4" DATE- -PERMIT'NO, + INFO - --f- +-- f I�j t � EH13-24IREV,tiKs) /�gS �S��Lib EH 14-28 L 4