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r - APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone 12091 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. - 9 T , Job Address D City Lot Size PM w Owner's Name Address r Phone Contractor o Address �� icense No.. �-Phone TYPE OF WELL/PUMP: NE WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ —� PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER El DISTANCE TO NEAREST: SEPTIC TANK 65 SEWER LINES DISPOSAL FLO,lgoaY- PROP. LINE 352 {i _ - ^�--FOUNDATION -- AGRICULTURE-W&I Lr--- __OTHER-WELL-.-w-----_.PITS/.SUMP-S,� i.INTENDED USE TYPOF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS F ❑Industrial ❑ Gravel Pack dustrial Open Bottom Manteca Dia. of Well Excavation Dia. of Well Casing i z ll ' C3 Tracy Type of Casing Specifications M Public n Other (7Delta Depth of Grout Seal Type of Graut, _ ._- I I irrigation Approx. Dept I`) Eastern Surface eel Installed by Repair Work Done ❑ Type of Pump .��-�(T'" H.P. State Work Done r Well Destruction ❑ Well Diameter _$ fl Sealing Material (top 50') Depth_ _q li 1n Filler Material I13elow 501 TYPE OF SEPTIC WORK; NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION l I (No septic system permitted if public sewer is available within 200 feet.) i tnstallation will serve: Residence— Commercial_ Other JI i Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth -SEPTIC TANK ❑ Type/Mfg . _-Capacity = No. Compartments P, " .K�. TREATMENT PLT. ❑ `` 54 ' Method of Disposal Distance to nearest: Well Foundation Property Line f . LEACHING LINE Cl No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well t Foundation Property Line SEEPAGE PITS 11 Depth Size Number _ SUMPS U1Distance to nearest: Well ' Foundation r Property Line :.DISPOSAL PONOS ❑ $ l t -f 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 5 .'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 f9r which this permit is issued,I shall employ persons subject to workman's compensa- tion laws of California.,' The applicant m call for ail require specti ns. Complete drawing on-r rse-side-- -•- v Signed X Title: Date: F DEPARTMENT USE ONLY Application Accepted by Dat1. Area Pit or Grout Inspection by Date ' Final Inspection by Date _1— I f Additional Comments: _❑ `Sfk 4&6-67$1 Lodi 369 3621 ❑.M-anteca !7104 Tracy, Applicant- Return-alt copies to;-Environmentab Health PermitlServices 1601--E-.-Hezefton•Ave.--P.-O:-8ox-2009,'StV` 'CA 95201 a FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. INFO CASH + EH{13-24 Wv.1/H 51 EH 1428