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1 , APPLICATION FOR PERMIT f SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA f: Telephone (209) 466-6781" , PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate), r,- App I ication ,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 Ryles and Regulations of the San Joaquin Local Health District. w ... /�Y - City /° fi}� Lot Size PM Job Address a ' Owner's Name Address t �.— License No. "" Phone Contractor �� Address - TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑^ i PUMP INSTALLATION..❑—,,,-.,_ SYSTEM REPAIR 0....�......_•_..... _OTHER,El �,:�•�9�� DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES ' bISROSAL FLD. PROP. LINE 1 FOUNDATION --AGRICULTURE WELL OTHER WELL PITS/SUMPS ; INTENDED USE TYPE OF WELL PROBLEM AREA LL CONSTRUCTION SPECIFICATIONS ,... Dia. l �Uia. of Well Excavation Casin [I industrial C1 Open Bottom ❑ Manteca \ Specof Welifications ❑ Domestic/Private ❑ Gravel Pack ❑,Tracy 4 '--4Type of Casing- 4 �''. El Public ❑ Other ❑ Delta Depth of Grout Seal `;:v, Type of Grout S ❑ Irrigation �Approx. Depth ❑ EastOrrn: Surface Seal_Inst_alied.by ism �_. State Work Done ' ; ` Repair Work Done ❑ Type of Pump.- H. - s•. c = k Well Destruction 13 Well Diameter f # -Sealing Material (top 50'),- Depth Y Filler Material (Below 50') I � { TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ DESTRUCTION 13 (No.rseptic system permitted if public sewer is ;'available,wilhin 200.feet.'); .1 . Installation will serve:" Residence Commercial Z Other ��e�' �A��> �'t Number of4Wj" units: Number of bedrooms J A Character of soil to a depth of 3 feet:` 1 + 4 a• �' "" f Water table depth '� ' SEPTIC TANK B/ Type/Mfg �R_y� Capacity /�fl _ No. Compartments - Method of Disposal . 1 PKG. TREATMENT PLT. ❑ Distance to ndarest: Well _ Foundation Property Line I i LEACHING LINE No.-& Length�of lines ` Total length/size iProperty FILTER BED ❑ Distance to nearest: Well ..-i Foundation 1'ZProperty'Lin6= e-dr! f , SEEPAGE PITS ❑ Depth '� 1 Size . t Numbed r_ SUMPS ❑ Distance to nearest WeII 'Foundation �" Property Line _ a: w DISPOSAL PONbS1 .jN❑ moi.=.ax I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county o#dinances;state laws rand rules and regulations of the San Joaquin Local Health District. This permit is issued, I shall not Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or,sub-contl.acting signature M 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 compsa- f tion laws of California." l s J to, 1 The applicant must call or all required)ns ns. Co "lete drawing on reverse side. { r ' f, _ .�rv//idyl Dae: Title: } 1 Signed , n.'yfvt.>s4 FOR DEPARTMENT USE Of�ILY { Application Accepted by )ate c Area Pit or Grout Inspection by `' I Date final Inspection by Additional Comments: j ❑ 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 9520 I FEE AMOUNT DUE ,w> AMOUNT REMITTED C H RECEIVED BY. - DATE PERMIT"NO. INFO i + EH 13-241REV.1/851 \� ti`s •�'`S p.� �S>� \7� � <_0 EH 1426 ✓ y _ T - - tm�..t '' -