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z APPLICATION FGR PERMIT SAN JOAQUIN .LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., .STOCKTON, CA Telephone (209) 466-6781 ', t PERMIT EXPIRES 1 YEAR FROM DATE ISSUED r",;" t� �y..,(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 / City t 1"1Lot Size PM- I Owner's Name /� 7�. . x, ui! � _ Address Phone i Contractor w 4 .nAddress License No.325-/4 Phone E TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ " PUMP INSTALLATION ❑ SYSTEM REPAIR _ OTHER LI _ DISTANCE TO-NEAREST:_SEPTIC TANK;" `__ �SEWER LINES-— - v -DISP_OSAL-FL-D--. �.. -PROP. LINE FOUNDATION+ AGRICULTURE WELL BOTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS s ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing -----Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal"., Type of Grout ❑ Irrigation ---Approx. Depth P Eastern SXace Seal Installed Repair Work Done Type of Pump 4 H.P. f f Z Y State Work Done . ` Well Destruction ❑ Well Diameter'�. Sealing Material (top 50') a Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic-system permitted if public sewer is Q available within 200 feet.) Installation will serve: Residence— Commercial_ Other 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 ' PKG. TREATMENT PLT. Elf♦ } r Method of Disposal Distance to nearest: Well Foundation Property-Line LEACHING LINE ❑' No. & Length of lines � Total.length)size i FILTER BED ❑ Distance to nearest WeII = ' "^Foundation ,Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ . I hereby certify that I have prepared this application and thaGthe work will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health Disirict, 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." Contractors 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 ap 7mucall for all requir i pection Comp a drawing on re side. Signed X ` : Title: / Date: 0 k FOR DEPARTMENT USE ONLY �+ ' Application Accepted by Date c Are J_�Jy Pit or Grout Inspection by ate Final Inspection by Dates Additional Comments: i ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 623-7104 _ © Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Silk., CA 95201 FEE CK* INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY k' DATE PERMIT'NO. �+ EH 13-24 1REV.1/1151 EH 14-26 /tit